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DERMATOLOGY 



THE MACMILLAN COMPANY 

NEW YORK BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FRANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
MELBOURNE 

THE MACMILLAN CO. OF CANADA, Ltd. 

TORONTO 



DERMATOLOGY 

The Essentials of Cutaneous Medicine 



BY 

WALTER JAMES HIGHMAN, M.D. 

Chairman, Section on Dermatology and Syphilology, American Medical Associa- 
tion; Member of the American Dermatological Association, and New York 
Dermatological Society ; Associate Professor of Dermatology, New York 
Post Graduate Medical School and Hospital; formerly Instructor 
in Dermatology, Cornell University Medical School; Acting 
Associate Dermatologist, Mt. Sinai Hospital, New York; 
Adjunct Dermatologist, Lenox Hill Hospital, New 
York; Pathologist, Department of Derma- 
tology, Vanderbilt Clinic, New York; etc. 



U3eto gorfe 

THE MACMILLAN COMPANY 
1921 

AU rights reserved 



T?LTi 

■ H5 



COPYEIGHT, 1921, 

By THE MACMILLAN COMPANY 



Set up and electrotyped. Published, January, 1921 



©CU605376 



TO 
HELOISE DAVISON HIGHMAN 



PREFACE 

In spite of otherwise great excellence, works on dermatology 
usually ignore the teaching needs of beginners. Cutaneous medicine 
is so confusing that, unless its study is gradually led up to, it appears 
chaotic. Indeed, frankness compels the admission that it is never 
quite simple, even to an accredited expert. Another reference book 
would have no justification. But this volume aims to present es- 
sentials succinctly, consecutively, completely and simply, without 
sacrificing important detail. Thus, in spirit, it is dedicated to the 
novice and to the general practitioner, too busy to grapple with tech- 
nicalities and abstractions. This group of readers should not be 
burdened with literary citations that cannot possibly interest them; 
nor with histological descriptions which, unless exhaustive and tech- 
nical, are valueless, and in any case incomprehensible except to 
pathologists; nor with elaborate historical sketches that are mainly 
exhibitions of pedantry. Accordingly, matter of this sort, unless of 
peculiar practical importance has been omitted since it would add 
to bulk rather than strength. 

Nothing germane has been sacrificed. What remains represents 
the author's conception of the minimum requisite for an adequate 
outline of the subject. Less important diseases appear in finer type, 
not to create an impression that they may be slurred, but to convey 
graphically their relative place among dermatoses. And to the 
practitioner also this arrangement will be welcome, for he will find 
the kernel without himself having to do the husking. Numerous 
tables have been compiled classifying diseases, their etiology and 
relationship, always with the combined idea of constructiveness and 
analysis. There is no excess of illustrations, but the pictures have 
been selected purely for their didactic value, and the points they 
purpose to clarify are categorically enumerated. Thus, although in 
number they do not compare with what is found in many other books, 
if properly used, they will prove adequate to the requirements of 
readers seeking a clear-cut impression of the ground work of 
dermatology. There are about four hundred more or less distinctly 
established skin conditions, and the beginner or general practitioner 
is probably not intimately concerned with more than one-quarter of 

vii 



viii PREFACE 

them. It is the smaller fraction that is accompanied by pictures, 
although the rest too are fully discussed in the text. 

The subject has been handled, so far as practicable, from the stand- 
point of internal medicine. The etiology of skin diseases, as a whole, 
is not yet well understood. Xevertheless, it is obvious that the 
integument is not autonomous, and that it is greatly influenced by, 
and greatly influences, the rest of the body. Premature and tenta- 
tive as must be beliefs connected with this interrelation, it is high 
time that they were stated, either to be sustained or overthrown in the 
future. They are set forth in this book, but our knowledge does not 
yet permit a classification of dermatoses solely on etiological grounds. 

Xomenclature in dermatology is discouraging, involved and often 
unsound. Some terms, however fanciful, have become permanent. 
Lichen is an example of this. Since its ancient symbolism con- 
notates something definite, there is no reason to assail it. Not so the 
word eczema ! The disease thus styled is one with vesicular derma- 
titis in aspect, causation, histology and course. Therefore, the 
sounder term should replace it. The word is nowhere independently 
employed in this book, but is used parenthetically after the expression 
dermatitis, wherever the latter appears. This compromise seemed 
expedient, for the undesirable term, not yet having been abandoned, 
must be continued until opinion becomes unanimous as to its 
further restriction. Scientifically, there is nothing to be said 
for the word eczema. We speak of occupational dermatitis and 
occupational eczema, of seborrhoeal dermatitis and seborrhoeal ec- 
zema, of fungus dermatitis and fungus eczema, of dermatitis of 
unknown origin and eczema of unknown origin, etc., always meaning 
in each couple the identical thing. This is a handicap, particularly 
since dermatitis, being philologically and medically an accurate desig- 
nation, is preferable ; and such writers as Gorman Walker, and Pusey 
have accepted the fact. Another complex subject is cutaneous tuber- 
culosis. Here again there has been a plethora of verbiage. So far 
as possible an effort has been made at simplification. Congenital 
syphilis, too, is masked by a literary smoke screen, partly through the 
inaccurate interpretation of the term hereditary, partly through a 
series of superstitions that still sustain about a comparatively simple 
thing an artificial cloud of obscurity. With the utmost respect for 
venerable traditions, it has been attempted to divest a difficult field 
of medicine of unnecessary encumbrances. 

As to therapy, the author has described only what has commended 
itself to him through personal experience. As knowledge grows 



PREFACE 



IX 



of the cause of, or of the relation of skin to general disturbances, 
treatment has become both simpler and better. This fact, and the 
precise accomplishments possible through the use of mechanical 
agents, such as the X-Rays, carbon dioxide snow and the like, indicate 
that in extensiveness the dermatological materia medica will shrink 
as therapy becomes more accurate. Treatment, symptomatology, dif- 
ferential diagnosis, and the significance of skin lesions in their rela- 
tion to morbid biology are the really important considerations. These 
constitute the theme of this book. It is hoped that students who 
seek a rational exposition of the essentials of cutaneous medicine 
will here find their requirements satisfied. The true dermatologist 
is an internist who knows the skin. 

The photographs appearing in this volume come from the collections 
of Dr. John A. Fordyce and Dr. George M. Mackee whom it is a 
great pleasure to thank for them. A similar expression of gratitude 
is extended to Dr. Jeffrey C. Michael for his valuable aid and 
suggestions. 

W. J. H. 

New York, K Y. 



CONTENTS 

SECTION A. GENERAL CONSIDERATIONS 

CHAPTER PAGE 

I The Etiology of Skin Diseases 3 

II Autochthonous Skin Diseases 8 

III Skin Diseases Which Are Not Autochthonous. Rela- 

tion of Dermatology to Internal Medicine .... 12 

IV General Considerations Concerning Cutaneous Lesions 18 
V Methods of Examination and Diagnostic Procedures . 26 



SECTION B. PUKE DERMATOSES 

Group 1. Cutaneous Reactions due Essentially to Vascular 
Disturbances 

VI The Erythemas and Urticaria 33 

VII Drug Eruptions, Exanthemata and Purpuras .... 55 

VIII Diseases of the Cutaneous Vessels; Telangiectases; 
Gangrene; Telangiectases and Vascular Diseases Ac- 
companied by Necrosis and Gangrene 83 



Group 2. Cutaneous Reactions Characterized by Serous 
Exudation 

IX Vesicular Diseases 98 

X Bullous Dermatoses 134 



Group 3. Cutaneous Reactions Characterized by Scaling or 

LlCHENIFICATION 

XI Psoriasis and the Psoriasiform Dermatoses .... 145 

XII The Erythrodermas or Exfoliative Dermatitis . . . 167 

XIII The Lichens and Lichenification 172 



Group 4. Epidermal Dystrophies and Hyperkeratoses 

XIV Epidermal Dystrophies; Dyskeratoses 185 

XV Hyperkeratoses 190 

XVI Hypertrophies of the Connective Tissue 197 

xi 



xii CONTENTS 

Group 5. Dystrophies of the Skin as a Whole 

CHAPTER PAGE 

XVII Atrophies of the Connects Tissue 204 

XVIII Pigmentary Diseases . 210 

XIX Degeneration of and in the Connective Tissue . . . 216 

SECTION C. PAKASITIC DISEASES AND INFECTIONS 
Group 6. Infections 

XX Diseases Caused by Multicellular Animal Parasites . 223 

XXI Infections Caused by Protozoa 233 

XXII Infections Caused by Fungi 239 

XXIII Streptococcus and Staphylococcus Infections of the 

Skin 261 

XXIV Miscellaneous Bacterial Infections 274 

XXV Tuberculosis and Lepra 279 

Group 7. Granulomata 

XXVI Granulomata (Non-Infectious) 304 

SECTION D. NEOPLASMS AND NEVI 

Group 8. Neoplasms 

XXVII Benign Epithelial Neoplasms 316 

XXVIII Malignant Epithelial Neoplasms 319 

XXIX The So-Called Precancerous Dermatoses 331 

XXX Benign Connective Tissue Neoplasms 337 

XXXI Malignant Connective Tissue Neoplasms . . . . . 341 

Group 9. Nevi 

XXXII Nevi 346 

XXXUE Diseases Which Are Probably Nevi 351 

SECTION E. DISEASES OF THE ORGANS OF THE SE1N, 
AND OF THE MUCOUS MEMBRANE 

Group 10. The Skin and Adnexa 

XXXTV Diseases of the Hair and Follicles 357 

XXXV Sebaceous Diseases 364 

XXXVI Diseases of the Sweat Apparatus 371 

XXXVTI Diseases of the Nails ...,...,,., 374 






CONTENTS xiii 

Group 11. Skin Diseases Eelated to Nerve Disturbances 

CHAPTER PAGE 

XXXVIII Cutaneous Disturbances Dependent upon or Associated 
with Nervous Disorders; Dermatoses Secondary to 
Central or Peripheral Nervous Diseases .... 379 



Group 12. Diseases of the Visible Mucous Membranes 

XXXIX Diseases of the Buccal Orifice, Conjunctiva, Anus and 

Genital Mucosa 383 



SECTION F. SYPHILIS 

XL General Aspects of Syphilis 391 

XLI Acquired Syphilis: Primary Stage 397 

XLII Acquired Syphilis: Secondary Stage 402 

XLIII Acquired Syphilis: Tertiary Stage 415 

XLIV Acquired Syphilis: Non-Cutaneous Manifestations . 423 

XLV The Management of Syphilis 430 

XLVI Congenital Syphilis 444 

Index 455 



LIST OF ILLUSTRATIONS 



Following page 

1. Erythema Exudativum Multiforme 54 

2. Erythema Nodosum 54 

3. Urticaria 54 

4. Urticaria Pigmentosa 54 

5. Prurigo 54 

6. Iododerma 82 - 

7. Bromoderma or Iododerma 82 

8. Bromoderma Tuberosum 82 

9. Herpes 133 

Zoster 133 

Dermatitis (Eczema), Acute Vesicular 133 

Dermatitis (Eczema), Crustosa or Madidans 133 

Dermatitis (Eczema), Palms 133 

Dermatitis (Eczema), Impetiginosa 133 

Dermatitis (Eczema), Thickened or Lichenified .... 133 

Pompholyx 133 

Pemphigus Vulgaris 144 *" 

Pemphigus Foliaceus 144 

Dermatitis Herpetiformis 144.. 

Psoriasis, Guttate 166 

Psoriasis, in Patches 166 

Parapsoriasis, Lichenoid Type 166 

Parapsoriasis, in Plaques 166 

Pityriasis Rosea 166 

Seborrhoea, Face and Scalp 166 - 

Seborrhoea, Body 166 - 

Lichen Planus 183 

Lichen Planus, Buccal 183 

Lichen Planus, Annular 183 v 

Lichen Planus, Hypertrophic or Warty 183 

Lichen Acuminatus or Pityriasis Rubra Pilaris .... 183 

Neurodermite, or Lichen Simplex Chronicus 183 r 

Molluscum Contagiosum 189 v 

xv 



xvi ILLUSTRATIONS 

Following page 

Fig. 34. Keratosis Follicularis Contagiosa, or Darier's Disease . . 189 

Fig. 35. Condyloma Acuminatum 189 

Fig. 36. Verucca Plana Juvenilis . 189 

Fig. 37. Keratosis Senilis or Seborrhoeal Wart 189 

Fig. 38. Keloid 203 

Fig. 39. Scleroderma with Atrophic Acrodermatitis 209 

Fig. 40. Morphoea 209 

Fig. 41. Xanthoma Tuberosum 219 

Fig. 42. Xanthelasma (Pollitzer) 219 . 

Fig. 43. Scabies 232 

Fig. 44. Pediculosis Corporis 232 

Fig. 45. Pediculus Pubis 232 

Fig. 46. Microsporosis 260 

Fig. 47. Tinea Capitis 260 ■ 

Fig. 48. Tinea Corporis 280 

Fig. 49. Kerion 260 

Fig. 50. Tinea Unguis 260 

Fig. 51. Dermatitis Due to Fungus Infection 260 v 

Fig. 52. Epidermophytia Inguinalis 260 

Fig. 53. Tinea Barbae 260 

Fig. 54. Favus 260 

Fig. 55. Blastomycetic Dermatitis 260 

Fig. 56. Impetigo Contagiosa 273 

Fig. 57. Ecthyma 273*/ 

Fig. 58. Folliculitis Barbae Staphylogenes 273 ^ 

Fig. 59. Rhinoscleroma 278 

Fig. 60. Granuloma Pyogenicum 278 

Fig. 61. Lupus Vulgaris 303 * 

Fig. 62. Lingual Tuberculosis 303 

Fig. 63. Papulonecrotic Tuberculides 303 

Fig. 64. Lupus Erythematosus Discoides 303 

Fig. 65. Lupus Erythematosus Discoides (Disseminated) .... 303 

Fig. 66. Erythema Induratum (Bazin) 303 

Fig. 67. Granuloma Fungoides 311 

Fig. 68. Leucemia Cutis 311 

Fig. 69. Epithelioma (Squamous Cell), Face 330 

Fig. 70. Same, Hands 330 

Fig. 71. Rodent Ulcer 330 

Fig. 72. Epithelioma, Tongue 330 

Fig. 73. Epithelioma, Lip 330 ~ 



ILLUSTKATIONS xvii 

Following page 

Fig. 74. Leucoplacia Buccalis 336 

Fig. 75. Kecklinghausen's Disease 340 

Fig. 76. Melanoma 344 

Fig. 77. Kaposi's Sarcoma 344 

Fig. 78. Alopecia Areata 363 

Fig. 79. Kosacea 370 

Fig. 80. Hunterian Chancre 401 

Fig. 81. Extragenital Chancre, Lip 401 

Fig. 82. Meatal Chancre 401 

Fig. 83. Vulvar Chancre 401 

Fig. 84. Macular Syphiloderm 414 

Fig. 85. Papular Syphiloderm 414 

Fig. 86. Small Papular Syphiloderm 414 

Fig. 87. Annular Syphiloderm 414 

£ig. 88. Mucous Patches 414 

Fig. 89. Condylomata Lata 414 

Fig. 90. Plantar Syphiloderm (Secondary) 414 

Fig. 91. Tubero-serpiginous Gumma 422 

Fig. 92. Tubero-ulcerous Gumma 422 

Fig. 93. Gummata (Shin) 422 

Fig. 94. Multiple Gummata 422 

Fig. 95. Palmar Syphiloderm (Tertiary) 422 



SECTION A. GENEKAL CONSIDEKATIONS 



DERMATOLOGY 

THE ESSENTIALS OF CUTANEOUS MEDICINE 

CHAPTER I 

THE ETIOLOGY OF SKIN DISEASES 

By far the most important "branch of the science of dermatology 
is the study of the causation of skin diseases. Upon definite knowl- 
edge of etiology alone depends rational treatment ; and in the care of 
dermatoses, as in all other diseases, only rational treatment can be 
successful. The struggle to classify disease, to increase precision 
in diagnosis, to recognize new diseases, has so engrossed scientists 
that the cure, the one thing of interest to patients, has by comparison 
been neglected. This is more emphatically true of dermatology than 
of most other subdivisions of internal medicine. Since the time of 
the great Viennese, Hebra, until recently, dermatologists have bent 
their efforts in the direction of classifying and arranging dermatoses 
mainly according to their clinical appearance. Thus there has de- 
veloped among dermatologists a slavish attentiveness to the minutest 
details of skin manifestations in the hope that by constant and further 
analysis of the lesions, their grouping and color, etc., a satisfactory 
classification or understanding of the diseases might be reached. 
This has engendered among dermatologists unthinkably keen powers 
of observation, and in dermatology excessive refinement as to the 
characteristic features upon the basis of which similar diseases are 
differentiated one from the other. 

The index to a work on dermatology thus is long, it would seem, 
to the point of attenuation, and to the medical student or to any 
reader who is not a dermatologist, both index and pages must appear 
almost chaotic. Nor can it be stated that the matter is entirely 
simple even for the specialist. The number of dermatoses recognized 
as clinical entities is enormous, and will so remain even after our 
criteria become more settled. We have already ceased to regard 
eczema of the axillae, scalp, face, body, genitalia, legs et cetera, and 
weeping, scaling and lichenified eczema as different diseases, although 



4 DERMATOLOGY 

there was a day when this disease, and many others, were subdivided 
in the manner above outlined, and when each subdivision was re- 
garded as a clinical entity. The most casual accident of appearance 
or localization was in itself considered sufficient for the creation of 
another skin disease. The disease was frequently designated in the 
tongue of the original observer, but more frequently still in Latin 
or Greek, or an unwholesome blend of both, and usually the name 
of the author was appended with a Latin genitive ending. These 
matters are mentioned to account for many of the avoidable sources 
of confusion in dermatology. A name is but a symbol, and just as 
every physician knows what Bright' s disease is, or hip disease, or 
a cold, although none of these designations is good, so every derma- 
tologist must accommodate himself to the disadvantages of such names 
as white-spot disease, lichen planus, eczema, pityriasis rosea; for if 
these names were to be changed, either the entire dermatological 
literature would have to be re-written, or discarded and re-com- 
menced. Neither of these two possibilities is practicable, so that 
it remains to revise our ideas on dermatoses partly with regard to 
their pathology, but more especially with regard to their causation. 
Hebra and his pupil, Kaposi, of Vienna, dominated dermatology 
during the last two decades of the past century, and their philosophy 
reduced to its lowest terms was one in which the integument was 
considered an organ largely dissociated from the tissues which it 
enveloped. They tended to regard all dermatoses as peculiar to the 
skin. This is all the more astonishing in view of the fact that it was 
Hebra who discovered the use of arsenic in one form of lichen, thus 
converting the latter from a serious to a mild disease. How one 
so astute as Hebra could at once maintain the doctrine of the inde- 
pendence of the skin from the rest of the body and attempt to cure 
a disease essentially restricted to the skin by internal medication 
is inexplicable. It is equally difficult to grasp why with so patent 
an illustration of the internal origin of dermatoses as in lichen, he 
failed to perceive its significance, and thus failed to try to clear up 
the origin of such diseases as psoriasis and many of the eczemas. 
But Hebra lived in a day in which the study of micro-organisms was 
engaging the world, and in which they were being held accountable 
for all diseases. Hebra was not a good bacteriologist, and he was 
an even worse histologist, although he sensed the importance of this 
subject, and referred for study to his former master, Eokitansky, all 
dermatological questions within this field. The bearing of bio- 
chemistry on dermatology was not even thought of in Hebra's time, 



THE ETIOLOGY OF SKIN DISEASES 5 

and questions included in serology and studies in anaphylaxis 
which to-day are engaging us, were then, of course, unknown. 

It must be remembered, however, that while the Teutons were 
endeavoring to restrict all dermatoses to the skin, the French had, 
for nearly a century, been approaching the problem by another ave- 
nue. As early as 1777 Lorry, in his " Tractatus de Mortis 
Cutaneis" under the Hellenic influence of the humoral causation of 
disease, sought to explain the etiology of many skin diseases by 
" arthritism." Alibert and Rayer actually tried to classify derma- 
toses on a basis of their internal causation. The Frankish tendency 
to correlate all given effects with definite causes, and to find for each 
an antidote or specific, led the Parisians and their followers far 
afield. Thus, while the Germans were cataloging dermatoses with- 
out reasoning backwards from them, the French were studying 
etiology without reasoning forwards. Until within recently the two 
extremes failed to meet. Then a few deductive thinkers endeavored 
to co-ordinate cause and effect, and a new era in dermatology began 
to dawn. 

In 1839 Schoenlein discovered the fungus which produces favus. 
In 1853 Gruby rediscovered the microsporon, which had been found 
by Audouin, and which causes a certain variety of ring-worm, while 
Eichstedt found the exciting agent of pityriasis versicolor, the micro- 
sporon furfur; and Barensprung that of erythrasma, the microsporon 
minutissimum. The significance of these discoveries was not re- 
alized until many years had elapsed when Pasteur and Lister re- 
vivified the study of bacteriology. During the last quarter of the 
Nineteenth Century this science was being ardently pursued, 
while that of histopathology was being quite as ardently 
developed. As regards bacteriology, enthusiasts sought to explain all 
diseases by the activity of microscopic agents, and the pendulum 
swung too far. Thus Darier regarded psorosperms, which were 
later found to be epithelial cell degenerations, as the organisms which 
caused the disease named after him ; Lustgarten isolated the bacillus 
which he held responsible for syphilis; Unna described a bacillus 
which he maintained to be the cause of acne. Unna was, however, the 
pioneer in cutaneous histopathology, and under his influence this 
science began to flourish. 

It is probable that the history of any branch of internal medicine 
would resemble that of dermatology. The clinical study of this 
subject is actually the macroscopic pathology of the skin. Its micro- 
scopic pathology bears the same relation to the dermatoses that the 



6 DERMATOLOGY 

microscopic appearance of any lesion anywhere in the body bears to 
its gross appearance. To a certain extent the etiology of disease may 
be illuminated by an understanding of its microscopic composition. 
To a larger extent, however, the etiology may be explained through 
the medium of bacteriology, biochemistry and serology in its broadest 
sense. A diagnosis should not merely be equivalent to labelling a 
disease, but should explain, subject to the limitations of human 
knowledge, its cause. Nothing may be neglected within the scope 
of physical diagnosis, laboratory diagnosis, or a knowledge of the 
course and character of illnesses, which furthers this end. Thus, a 
dermatologist must be equally a clinician, and a student of the sig- 
nificance of laboratory procedure, if not actually a trained laboratory 
worker. Only then may he aspire to be an intelligent and successful 
therapeutist. In other words, dermatology is not a science mi 
generis, but a branch of internal medicine with all that this concept 
implies. 

Every organ, not excepting the skin, is subject to two large 
groups of morbid processes, those peculiar to itself, and those 
which include it in the course of systemic disease. The former 
are autochthonous ; the latter are due to the participation of the given 
organ in the general pathological reaction of the body. In the 
second group the local reaction is modified by the anatomic and 
physiologic peculiarities of the given organ. Thus in syphilis, the 
skin is differently affected from the meninges, although in the 
pathological changes in both may be found common features. The 
same is true for example of leukemia, Hodgkin's Disease and tuber- 
culosis. Furthermore, systemic diseases may predispose to skin 
diseases of an entirely different nature, as diabetes, in which the 
skin may remain normal, be slightly inflamed, itch more or less, 
become infected with pus organisms, or become gangrenous. Further 
illustrations would be superfluous. 

Pure diseases of the skin are numerous. Professional dermatoses, 
erythrasma and ring-worm will serve as examples. Even here, 
however, the autonomy of the skin is incomplete, for in deep ring- 
worm, a cutaneous disease pure and simple so far as human eye may 
discern, there is a systemic response. The serum of individuals 
afflicted with this malady gives specific and group reactions when 
the Bordet-Gengou test is applied, and the skin of such patients 
manifests allergic phenomena in the sense of von Pirquet. Not 
every charwoman develops a dermatitis of the hands, nor every sur- 
geon a bichloride rash; not every human being exposed gets ring- 



THE ETIOLOGY OF SKIN DISEASES 7 

worm or ivy poisoning. Thus, even in these dermatoses more is 
required than the mere operation of an external agent. A predispo- 
sition on the part of the patient is needed, and the significance of 
this is the presence of some anatomic, physiologic or metabolic char- 
acteristic which favors his liability to an illness to which his brother 
is not subject. 

Thus the distinction between dermatoses considered local and 
dermatoses which are not, is more one of convenience than one which 
will withstand the test of fine philosophic analysis. It is neverthe- 
less a distinction of practical value in arranging and classifying skin 
affections, although more or less arbitrary. 



CHAPTER II 

AUTOCHTHONOUS SKIN DISEASES 

Autochthonous maladies of the skin are either congenital or ac- 
quired. The congenital types are either accidental, that is, peculiar 
to the newborn individual himself; or hereditary, that is, trans- 
mitted from an immediate or remote ancestor to the newborn indi- 
vidual by virtue of some property of the chromosomes of the parental 
cells. No expressions are more loosely used in medicine than the 
words hereditary and congenital. Not every condition that is con- 
genital is hereditary, or there would be in nature no such thing as 
variation, the fundamental requisite for the origin of species. On 
the other hand, every hereditary characteristic, whether actually 
present at birth or not, is congenital. If it is not present at birth, 
but develops after weeks, months, or years, it is an hereditary charac- 
teristic evincing itself later in life, the congenital impulse to which 
has until then been dormant. 

Congenital diseases of the skin which are usually not hereditary 
are nevi. Ichthyosis may be congenital and either hereditary or not 
hereditary. It may also appear later in life as an hereditary or non- 
hereditary disease. The determination of this point, not only in 
ichthyosis but whenever similar questions arise, will depend entirely 
upon the family history. Keratosis palmaris et plantaris heredit- 
aria is a family disease which is rarely present at birth. The same 
is true of monilethrix. Acquired dermatoses are caused by physical 
and chemical agents, vegetable and animal parasites, undiscovered 
infectious agents, and by the influences of occupation, habit, environ- 
ment, race, age and sex. Before proceeding with a further discussion 
of these facts, it may be desirable to present them in tabular form 
with simple illustrations. 

Group 1. Congenital and Hereditary Diseases 

Section A. Congenital Diseases J Nevi — Most Forms. 

(Not Hereditary) \ Ichthyosis — Some Forms. 

f Nevi 1 

Section B. Congenital Diseases I I gome Forms 

(Hereditary) ] Ic hthyosis J 

8 



AUTOCHTHONOUS SKIN DISEASES 



Section C. Hereditary or Family- 
Diseases 
(Delayed in Appearing) 



Ichthyosis — Some Forms. 

Epidermolysis Bullosa Heredi- 
taria. 

Keratosis Palmaris et Plantaris 
Hereditaria. 



Section A. 

1. Light 

2. Heat 

3. Cold 



Group II. Acquired Diseases 

Physical Agents. 

Sunburn. 
X-Eay Burns. 

X-Ray Keratoses and Epithelio- 
mata. 

Burns whether due to fire, elec- 
tric sparks, or hot substances. 

Frost-bite. 



{ 



4. Exposure | 

5. Pressure 4 



Seaman's skin. 



Clavus. 
Callous. 

Section B. Chemical Agents. 

All cause vesicular, bullous urti- 
carial or ulcerating dermatoses. 

1. Metallic and Non-metallic Ele- 
ments. 

2. Acids and Acid Salts. 

3. Alkalis and Alkaline Salts. 

'Rhus toxicodendron. 



4. Vegetable Poisons - 



Poison Oak. 
Primrose. 

Nettles. 

5. Vegetable and Mineral Oils and 

Tars (Tar Acne). 

f Mineral. 

6. Dyes -j Vegetable. 

[ Aniline. 

Section C. Vegetable Parasites. 
1. Bacteria 



A. Cocci, Streptococci 



Staphylococci < 
B. Bacilli | 



Impetigo contagiosa. 

Erysipelas. 

Erysipeloid. 

Folliculitis. 
Furunculosis. 



Tubercle bacillus — T.B. verrucosa cutis. 
Klebs-Loeffler bacillus — Impetigines. 



10 DERMATOLOGY 



2. Fungi 



Commonest examples, pityriasis 
versicolor (microsporon furfur) 
and various types of ring- 
worm, favus, etc. 

Section D. Animal Parasites. 

1. Protozoa j Oriental boil. 

2. Closely related to protozoa, or 
protista, Spirochaeta causing ver- 
ruca Peruana, not to be confused 
with Oroya fever, which is a sys- 
temic disease caused by a bacillus. 

Pediculosis. 



3. Insects, etc. 



Scabies. 

Stings of bees, mosquitoes, wasps, 
bed-bugs, larva migrans. 



4. Jelly fish. j Wheals. 

5. Vermes < 



Leech-bite. Anal eczema from 
thread worms, etc. 

Section E. Undiscovered Infectious 
Agents 

^ -».- n . Recently Wile has discovered a 

1. Mollscum contagiosum. «,, ,, „ , 

2. Verruca plana. 1 * ltrable 7 1 ™ capable of pro " 

L ducmg these lesions. 

Section F. Occupation. 

Surgeons, nurses, orderlies, charwomen, employees in slaughter houses, 
factories, etc., are prone to develop a great number of dermatoses, mostly 
on the hands. The immediate causes of these diseases are such 
physical or chemical agents as are peculiar to their particular work. 
See Group II., Section A., 1-5; and Section B., 1, 2, 3, 5 and 6. 

Section G. Habit. 

Habit and occupation are closely related. The manner of holding tools 
and utensils may determine the location of callouses or injuries on the 
hands. Inadvertent mannerisms, such as scratching, nail biting, biting 
of the cuticle will determine corresponding injuries. Hysterical and 
designing individuals inflict upon themselves injuries by divers 
methods and means. 

Section E. Environment. 

Inmates of institutions, children at schools, people living crowdedly in 
filth, are exposed to infections caused both by animal and vegetable 
parasites. Geographical considerations, too, should be included under 
this heading. Thus, piedra is a fungus disease of the South (in the 
region of Panama) ; verruca Peruana is found only in a certain dis- 
trict of the Andes ; Oriental boil is peculiar to countries on the North- 
eastern and Southern shores of the Mediterranean and Southern Asia. 



AUTOCHTHONOUS SKIN DISEASES 11 

Section I. Race. 

Negroes are peculiarly predisposed to keloids. Madura foot, caused by 
an organism closely related to the ray-fungus, is more frequent among 
natives of India and Africa than among aliens. 
Section J. Age. 

Certain types of ring-worm, molluscum contagiosum and verruca plana 
are rare, except in childhood. A characteristic type of wart known 
as senile hyperkeratosis is restricted to the period of life its name 
suggests. 
Section K. Sex. 

The two sexes present about the same series of dermatoses. Such varia- 
tions as the lesions may show are due rather to anatomical peculiarities 
than to any inherent sex differences. 

Kace, age and sex are minor considerations in their etiological 
relation to pure dermatoses, as compared with the rest of the fore- 
going table. Study of this table will also show a high degree of 
interdependence among the various factors. For instance, diseases 
of occupation (Section F) depend directly upon their causation for 
some chemical agents (Section B) and some physical agents (Sec- 
tion A) and infectious agents (Section D). Diseases are due to 
environment (Section H) only in a passive and subsidiary sense, 
for it is due to the environment that the infectious or other active 
agents (Sections C, D and E) gain access to their host. It is 
important, too, to bear in mind the fact that not every worker 
exposed to given chemical, physical, or other pathogenic influences, 
nor every child exposed to ring-worm or pediculi, becomes diseased. 
As already stated (Chapter I), the patient must be receptive to the 
disease which the pathogenic agent is capable of producing. Whether 
this predisposition is due to race, age, sex, occupation, environment, 
individual peculiarity, or a combination of these makes no difference, 
and in so far as this is true there are very few pure skin diseases. 
For practical purposes, however, it is simpler to accept the existence 
of such a group, although by no means in the restricted and isolated 
sense it has heretofore possessed. 



CHAPTER III 

SKIN DISEASES WHICH ARE NOT AUTOCHTHONOUS. 
RELATION OF DERMATOLOGY TO INTERNAL MEDICINE 

Although, as has been indicated, the line of demarcation is no 
sharp one between skin diseases which may for convenience be termed 
local, and those which in no sense may be so termed, the relationship 
of the second group to internal medicine is not entirely clean-cut. 
Psoriasis, for example, lichen planus, prurigo, pemphigus and der- 
matitis herpetiformis are more emphatically characterized by their 
cutaneous manifestations than by any general symptoms they cause, 
or with which they are associated. It is nevertheless impossible to 
be familiar with these diseases and many others without becoming 
convinced that the part the skin plays in them, though conspicuous, 
is incidental, and that their causation must be sought elsewhere than 
in the integument. It is possible that any or all of these diseases 
may be due either to specific skin parasites, operating locally, to a 
specific internal infection which causes definite cutaneous changes, or 
to some metabolic or biochemic disturbance giving rise to charac- 
teristic alterations in the skin. Even admitting the likelihood of 
a specific local infection in these diseases, their course is such as to 
suggest that some internal disturbance is required to fertilize the 
soil for the local agent, in which case the local factor after all 
becomes the incidental one. 

There are, indeed, not many ways in which the skin may be path- 
ologically altered, so that many processes which are widely separated 
as to their origin may be characterized by like or closely allied 
cutaneous manifestations. Both urticaria and dermatitis aptly il- 
lustrate this. The wheals of urticaria are all alike. The causes of 
urticaria are numerous. The flesh of fish, Crustacea, beef, molluscs, 
egg albumin, strawberries, alien serum, and many other substances, 
known and unknown, in receptive individuals cause urticaria. The 
disease is simple to recognize, but its cause in given cases is usually 
difficult to ascertain. Acute and chronic dermatitis, a vesicular and 
scaling disease, may be provoked by rhus, primroses, bichloride, 
dye-stuffs, vanilla, essential oils, wood oils, pollens, many varieties of 
chemicals, and by a host of internal causes. ]STor can dermatitis be 
clinically or histologically differentiated from eczema. Here again 
the problem is to discover the ultimate cause of the disease, that is, 

12 



SKIN DISEASES WHICH ABE NOT AUTOCHTHONOUS 13 

to find out what the interrelationship is between the skin and the rest 
of the body. 

Skin lesions primarily or secondarily due to an internal cause 
are called cutaneous reactions. Thus, the urticarial wheal; the 
vesicle of acute eczema or dermatitis; the erythematous blotches 
caused by copaiba, antipyrin or phenacetin, ptomaines, bacteria or 
their toxins ; the scarlatinif orm rash of scarlet fever, or belladonna 
poisoning; the herpetic vesicles of true herpes, or associated with 
arsenic poisoning or grippe — all respectively are examples of types 
of cutaneous reactions, similar in appearance but due to a wide 
variety of causes. 

Diseases of the skin which are not local are either those in which 
the skin participates in a systemic disease, or those in which a dis- 
ease, beginning in the skin, becomes systemic. The only real differ- 
ence between the two is one of sequence, for in the second group the 
skin is the starting point of the malady, instead of being merely a 
participant. Extensive burns and infectious diseases such as erysip- 
elas, syphilis, glanders and anthrax are illustrations. It must by 
now be clear that the physiologic and metabolic balance of the human 
organism is shared to no small degree by the skin, and that the part 
played by internal medicine in dermatology is large. But this inter- 
relationship is no simple one to trace. A classification of dermatoses 
from this standpoint is difficult to compose, and roughly parallels 
that in the preceding chapters. The following list though not com- 
plete, suggests by common examples the scope of the field under dis- 
cussion. 



Section A, 



Section B. 



Section C. 



Section A. 



Group I. Congenital and Hereditary Diseases 

Congenital Diseases 
(Not Hereditary) 

Cogenital Diseases 
(Hereditary) 



Syphilis. 

Icterus neonatorum. 

Some types of hemophilia. 



Hereditary or Family 
Diseases. 
(Not Congenital) 



Xeroderma pigmentosum. 
Hemophilia. 



1. Erythemas 



Group II. Acquired Diseases 

Chemicals and Drugs. 

Belladonna. 

Copaiba. 

Many of the coal tar products. 

Arsenic 



14 



DERMATOLOGY 



2. Vesicles and Bullae 

3. Pustules 

4. Wheals j 

5. Granulomata J 

6. Pigmentation 

7. Epithelial proliferation 



Arsenic 

Bromides. 

Iodides. 

Iodides. 
Bromides. 

Quinin, the balsams, sera, anti- 
toxins, vaccines. 

Iodides. 
Bromides. 

Arsenic. 

\ Arsenic. 



Section B. Vegetable Parasites. 



1. Bacteria 



2. Bacterial Toxins 



3. Fungi. 



Lepra, Lupus vulgaris and other 
forms of cutaneous tuberculosis, 
blennorrhagic granuloma, gland- 
ers anthrax, typhoid roseola, 
typhus roseola, various eruptions 
associated with erythema nodo- 
sum and sepsis. 

Toxi-tubereulides, toxins of 
streptococci and staphylococci in 
sepsis, accompanying angina of 
streptococcus origin causing some 
varieties of multiform erythema, 
and allied diseases. 



Actinomycosis 
sporotrichosis. 



blastomycosis, 



Section C. Animal Parasites. 

1. Protozoa or Organisms closelvf 
allied 1 



2. Vermes 



Syphilis. 
Yaws. 

Urticaria accompanying echino- 
coccus and other parasitic infec- 
tions. 



Section D. Undetermined Infections — The Acute Exanthemata: 

Scarlet, measles, chicken and small pox, German measles, Duke's dis- 
ease; probably some forms of erythema multiforme, and possibly pity- 
riasis rosea. 



Section E. Toxins — Anaphylatoxins. 
1. Anaphylatoxins 



Urticaria and probably some 
forms of dermatitis; prurigo. 



SKIN DISEASES WHICH ARE NOT AUTOCHTHONOUS 15 



a. Disturbed nitrogen metabolism 



2. Toxins expressing faulty metabolism. 

Some dermatitis, dermatitis her- 
petiformis, and Hitters' derma- 
titis; forms of infantile derma- 
titis; Leiner's erythroderma des- 
quamativa congenita. 

Diabetic dermatitis, carbuncle, 
furunculosis, gangrene. 
Hyperglycemia, diseases of the 
pilosebaceous system, sycosis, ros- 
acea, furunculosis, acne, sebor- 
rhoea and seborrhoeal dermatitis, 
some forms of infantile derma- 
titis. 



b. Disturbed sugar metabolism 



c. Disturbed fat and cholesterin J 
metabolism \ 

3. Gastro-intestinal indigestion. 

a. Gastric hyperacidity, chronic] 
gastritis, athylia gastrica, etc.] 

b. Carbohydrate fermentation. 

See Section E. 3, a. 

c. Disturbed pancreatic and liver function. 

See Section E. 3, a. 

d. Proteid putrifaction associated 

with disturbed nitrogen me- 
tabolism, or changed perme- 
ability of gut, allowing of 
absorption of anaphylatoxins 
or other toxins. See Section 
E., 3, a. 

4. Eenal disturbance, part of dis- 

turbed nitrogen or sugar me- 
tabolism. 



Infantile dermatitis, xanthoma 
tuberosum. 



Acne, rosacea, seborrhoea, closely 
allied to disturbed sugar metab- 
olism. 



Section F. Disturbances of Internal Secretion 

Skin 



1. Thyroid. 



2. Adrenals and Chromaffinic 
System. 



changes in cretinism, 
Graves' disease; effect of thyroid 
on sugar metabolism through 
pancreas and liver. 

See Section E., 2, b. 

Pigmentation, Addison's disease, 
bronzed diabetes; possibly vit- 
iligo. 



16 



DEKMATOLOGY 



3. Pituitary Body. 



Skin disturbances in acromegaly, 
hirsutes and effect of gland upon 
sugar metabolism. 

See Section E., 2, b. 



Section G. Disturbances of Primary and Secondary Sexual Organs 
(possibly of internal secretions). 



1. Puberty (both sexes). 

2. Menstruation. 

3. Pregnancy. 



4. Menopause. 

Section H. Nervous System. 
1. Central. 



2. Peripheral. 



Acne; in women, hirsutes. 
Acne, vaso-motor dermatoses. 
Acne, eczema, pruritis, urticaria, 
vesicular and bullous dermatoses, 
fibromatosis, hyper-pigmentation, 
hirsutes. 

Dermatitis, rosacea, vaso-motor 
dermatoses. 



Gangrene, herpes, malum perf or- 
ans pedis, pellagra, neurotrophic 
disturbances of syringomyelia, 
multiple sclerosis, tabes; trau- 
matic alopecia, decubitus, sclero- 
derma. 

Pruritus and herpes ; dermatalgia 
andf possibjly symmetrical gan- 
grene. 



Section I. Visceral Malignant Neoplasms. 

Cutaneous metastases, acanthosis 
nigricans, pigmentations. 

Section J. Cachexias and Prolonged Fevers. 

Dry skin, sudamina, alopecia, nail 
distrophies, pigmentations, exfol- 
iating erythrodermas, etc. 

Section K. Diseases of the Blood, Lymph and Blood and Lymph making 
Systems. 

Leukemic and pseudo-leukemic 
infiltrations of the skin, premy- 
cotic dermatoses, erythrodermas. 

In other chapters of this book the outline just sketched in will "be 
amplified as each disease is discussed. It is the sole object of this 
chapter to emphasize that dermatology belongs to internal medicine, 
and that the dermatologist should be less a reservoir of special 
designations than an internist regarding internal medicine with an 



SKIN DISEASES WHICH AEE NOT AUTOCHTHONOUS 17 

especial view in mind to which he must train his eye. Conversely 
too, the internist of the future would do well to be more of a 
dermatologist than his forefathers have been. The belief has flour- 
ished that the dermatologist is no physician, and that an internist 
need not and cannot understand dermatology. Neither is true, al- 
though to judge from the past, the latter belief has a better founda- 
tion than the former. 



CHAPTER IV 

GENERAL CONSIDERATIONS CONCERNING CUTANEOUS LESIONS 

A skin disease is characterized by the appearance upon the in- 
tegument of some visible or palpable variation from the normal. 
The normal aspect of the skin among the different races of man is 
too well-known to demand description. Pathological alterations are 
called cutaneous lesions, and the lesions are either level with the 
surface of the skin, depressed or raised. They are further charac- 
terized by their color, shape, size, consistency, grouping and distribu- 
tion. Fresh lesions have certain definite attributes which are subse- 
quently modified either in the course of their evolution or involution, 
or altered by traumata such as scratching, rubbing and the applica- 
tion of medicaments. Fresh lesions are called primary and all the 
others secondary. 1 It is by a study of the former in most cases that 
we must learn to recognize dermatoses, for the former tend to be 
characteristic and specific, while the latter are generic in type. The 
presence upon the skin of lesions is called an eruption, outbreak or 
rash. All of these terms date back to a time in the history of 
medicine when it was thought that poisons within the body, in their 
effort to escape, attacked the skin before leaving. The primary or 
elementary lesions of the skin are the macule, papule, tubercle, 
tumor, vesicle, bleb, pustule and wheal. 

Macule means spot, stain or blotch, and the macule is either flush 
with the skin surface or very slightly depressed, but varies in size from 
bare perceptibility to any dimensions. Its color may be white, pink, 
red, buff, brown or bluish, and its border may be sharp or blurred. 
Its shape may be circular, oval, elliptical or irregular, and finally 
macules may remain discrete or become confluent. The tiniest 
macules are found among petechiae in sepsis and the hemorrhagic 
diseases, the largest among the flat nevi. Examples of the white 
macules are found in vitiligo, pink, in the rose spots of typhoid and 
syphilis, red, in syphilis, and the toxic eruptions; buff, in 
pityriasis versicolor, and in syphilis in seborrhoeal individuals. 
Brown macules are seen in freckles, chloasma and nevi; bluish, in 

i These terms must not be confused with the primary and secondary lesions of 
syphilis. 

18 



CONCEKNING CUTANEOUS LESIONS 19 

certain nevi, and the maculae ceruleae in pediculosis corporis. The 
only examples of depressed macules are found in some of the 
atrophies. 

Papules are small cutaneous elevations varying in magnitude 
from the minutest visible size to about the dimensions of a coffee 
bean. They may be either curved, conical or have vertical sides, 
and in outline they are either circular, elliptical or polygonal. They, 
too, may vary in shade from pink to deep red, bluish to violaceous, 
and light yellow to deep brown, or even slate colored or black. They 
are either single, grouped or confluent, and rest upon a non-inflamed 
or inflamed base. Examples of conical papules are those of lichen 
acuminatus; of curved, lenticular syphilitic papules; of steep 
papules, those of lichen planus. Circular papules are found in 
syphilis, psoriasis and prurigo; elliptical ones in pityriasis rosea; 
and polygonal types in lichen planus. The coloring and grouping 
will be further discussed in the descriptions of the various diseases. 
Included among the papules should be a larger variety called the 
tubercle, its maximum diameter being about two centimeters. Small 
neoplasms such as nevi, epitheliomata and gummata and the lesions 
of erythema nodosum furnish illustrations of this lesion. Node and 
nodule are synonyms of tubercle, and it must further be remembered 
that when used in this sense the word tubercle has no connection with 
tuberculosis. A further distinction between papules and tubercles 
is based upon the level of the skin in which they lie. Papules tend 
to originate in the upper levels of the corium and epidermis, while 
tubercles originate in the lower levels of the corium and sub-cutaneous 
tissue, growing thence upwards. Both papules and tubercles vary 
in consistency as well as in the respects already mentioned. They 
may be soft as in fibromata, or hard as in gummata, sarcomata and 
non-ulcerated syphilitic primary lesions. 

Skin tumors are solid elevations the dimensions of which vary 
from those of a tubercle to the size of oranges, and occasionally skin 
tumors, such as lipomata, reach huge proportions. For the most 
part tumors are of neoplastic origin, but large ecchymoses, gummata 
and leprides reach such dimensions as to entitle them to be classed 
as tumors. The color, consistency, shape and number of tumors is 
determined by the malady of which they are the feature. A last 
attribute of these lesions to be mentioned is their mode of connec- 
tion with the skin. If their base is not constricted tumors are spoken 
of as sessile. If their base is constricted, they are spoken of as 
pedunculated. 



20 DEKMATOLOGY 

Vesicles are collections of fluid in the epidermis, or between the 
epidermis and papillary body, sometimes invading even the latter, 
and they almost invariably indicate an exudative inflammation. 
Excepting for vesicles formed by an accumulation of sweat in the 
mouths of occluded sudorific ducts, the contents consist of serum 
or serum and blood. In a like manner all vesicles are of inflamma- 
tory origin except some sweat vesicles and the lymph vesicles found 
in a rare disease called lymphangioma circumscriptum, which may 
be a neoplasm or nevus. For the most part vesicles rise above the 
surface of the skin, but when the epidermis forming their roof is 
thick, as on the palms and soles, they remain level. Elevated vesicles 
are conical, curved or hemispherical and their greatest size is that of 
a coffee or kidney bean. They are either tense or flaccid and their 
color is determined by that of their contents. Sweat vesicles are 
crystalline in appearance resembling dew drops. Vesicles containing 
clear serum are straw-colored ; those filled with serum and blood may 
be pale pink or deep brown, or any shade between these two, subject 
to the relative proportions of serum and blood. Vesicles are single 
or grouped and may remain discrete or coalesce. Dermatitis, derma- 
titis herpetiformis, herpes, miliaria crystallina are vesicular diseases. 

Bullae or blebs are to vesicles what tumors are to papules or 
nodes. A bulla is an accumulation of fluid varying in size from 
a lima bean to almost any dimensions. Their color, consistency, 
grouping and site are determined in a manner identical with those 
of vesicles. Their contents are invariably either serum or serum 
mixed with blood. 

Pustules are collections of pus in or just below the epidermis. 
They are caused by a secondary infection of vesicles or bullae, 01 
they arise spontaneously as in impetigo contagiosa. Serum and blood 
may be admixed with the pus. Pustules are white, yellow or 
greenish according to the nature of the process and the variety of 
the exciting organism. These colors are capable of further modifica- 
tion by the presence or absence of serum and blood, and the relative 
quantities of these fluids. Some pustules are sterile as is usually 
the case in pustular syphilides. Variola, impetigo contagiosa, syco- 
sis and glanders are some examples of pustular diseases. Pustules 
mimic both Vesicles and bullae in shape, size, consistency and 
grouping. 

Wheals are caused by spasm in the cutaneous vessels effecting 
a temporary stasis of blood. When the spasm is overcome, the wheal 
gradually vanishes. Thus, wheals are transitory. In color they 



CONCEKNING CUTANEOUS LESIONS 21 

are dead white, pink, or red. Their shape varies and they may be 
as large as a hand or even greater in dimension, as in giant urticaria. 
Fresh mosquito bites furnish good examples of the usual type of 
this lesion. In fading, wheals sometimes leave a pink macule and 
rarely a hyper-pigmentation. 

Secondary or consecutive lesions are the scale, crust, excoria- 
tion, rhagade, ulcer, cicatrix and lichenification. In a sense some 
of the primary lesions may be secondary. A papule, for example, 
often is the later stage of a macule; a vesicle, the later stage of a 
papule; a bleb, or pustule, of a vesicle; or all of these types of 
lesions may be present at the same time, a condition observed in 
dermatitis and dermatitis herpetiformis. These are not, however, 
consecutive lesions in the strictest sense of the term as it is usually 
employed. 

Scales are a mass of exfoliated epidermis engendered by a patho- 
logical process in the skin. They are made up of cells of the stratum 
corneum, and surmount macules and papules as in the toxic derma- 
toses or psoriasis; or, they are formed in the involuting stages of 
vesicular and bullous diseases, such as dermatitis and pemphigus. 
Finally, they must be present in cutaneous anomalies such as ichthy- 
osis. They may be adherent to the epidermis below, requiring rela- 
tively great force to secure their removal, or they may come off with 
great ease. They are either very fine and small, or large and thick. 
Some are veritable casts of parts from which they spring, a condi- 
tion at times seen in the exfoliation of the hands and feet after 
scarlatina. They are either dry or greasy, white, yellowish or 
brownish, and occur in solid flakes or in flakes resembling pie crust. 
Very fine scaling is described as branny or f urf uraceous. Scales 
may be few in number and sparsely shed, or very numerous falling 
off in powdery showers, or in great flakes, or even sheets. 

Crusts result from the drying of skin exudations. They cover 
surfaces denuded of epidermis, as in dermatitis, impetigo or burns ; 
they surmount ulcers, fissures, excoriations, scratched papules, vesi- 
cles or bullae. They are either adherent or easily removable. Their 
size, shape and grouping are determined by these characteristics in 
the underlying lesions. They tend to be slightly convex and consist 
of a single layer, or of numerous layers suggesting the appearance 
of an oyster shell. They consist of dried serum or blood, or both, in- 
termingled with scales and at times hairs. Extraneous matter may 
be included, such as dirt, bacteria and grease. Their color depends 
upon their main constituent. If serum alone is present they are 



22 DERMATOLOGY 

as yellow as honey; if blood alone makes up the crust, the color is 
brown. Should blood and serum both be represented, the color will 
be determined by the relative proportion of these substances. Dirt 
and bacteria impart to the crusts a greenish, grayish or muddy ap- 
pearance. Crusts are hard or soft, brittle, powdery or tough. 

Excoriations are solutions in the continuity of the epidermis, 
produced by trauma. The trauma may be involuntary — the scrape 
of a pin, the rubbing of a garment, etc., but usually it is voluntary 
and purposeful, namely, to relieve itching. Insect bites and pruri- 
ginous dermatoses are relieved by such trauma in the form of 
scratching. The character of the excoriation varies. Should 
papules or vesicles be scratched, the excoriation is usually punctate 
and corresponds to the apex of the lesion. Should extensive surfaces 
be scratched, the excoriations are usually linear and often parallel. 
At times the scratching is so severe and frequent as, of itself, to be 
a source of irritation, and the excoriations may serve to mask the 
characteristic lesions of the disease, as in scabies, and pediculosis 
corporis. In areas of the body inaccessible to the hands, excoriations 
are often produced with implements, the character of which will 
determine the type of the excoriations. These may be punctate, 
striated or irregular in outline and depth, sometimes amounting to 
actual tears. Deep excoriations leave scars and are often followed 
by hyperpigmentation. 

Rhagades are solutions in the continuity of the epidermis and 
immediately subjacent skin, occurring in areas of infiltration, and 
usually at points at which the integument is subjected to increased 
tension as over extensor surfaces of joints, or subjected to folding as 
over flexor surfaces, or near body folds. They are also frequently 
found at muco-cutaneous junctions. They are linear, and their 
length is determined partly by the size of the infiltrated area in 
which they occur, and partly by their anatomical site. A rhagade 
under the breast may be as long as the junction between the breast 
and adjacent thorax. At the corner of the lips rhagades are as long 
as the depth of tissue lying beneath the skin without and the mucous 
membrane within. These lesions are also called fissures. They are 
found in dermatitis, callous, in connection with mucous patches, and 
in general with all infiltrations. They predispose to ulcerations and 
at times become portals of entrance for infecting organisms leading 
to local infections, cellulitis, or even sepsis. 

Ulcers are solutions in the continuity of the skin involving the 
epidermis and the tissues below to any depth. The papillary body 



CONCEKNING CUTANEOUS LESIONS 23 

alone may be involved, or the cellular tissue may be included, as ( 
well as fascia and even muscles. An ulcer implies necrosis, and 
the process may have many causes. Ulcers vary in shape, size, the 
character of their margins and their floors, and as to the nature of 
their discharge. They may be caused mechanically by pressure or 
cutting; chemically, by caustics; thermally, by freezing or burning, 
and by actinic rays. Diseases of the central nervous system, cach- 
exias and wasting fevers causing trophoneuroses lead to ulceration, 
whether in the form of gangrene or bed sores or pressure sores. In- 
fections by streptococci, spirochaetes, lepra, tubercle bacilli, Klebs- 
Loeffler bacilli, etc., lead to ulceration, as do various types of 
neoplasms. 

The shapes which ulcers may assume are circular, elliptical, cir- 
cinate and irregular. Circular and elliptical ulcers are in the main 
those of mechanical or chronic infectious origin. Circinate and ir- 
regular ulcers are caused by confluence of the first two types, and 
by infectious and chemical, actinic and thermal agents. The mar- 
gins of ulcers may be either vertical or at an angle to the base 
causing the opening of the ulcer to be larger than the floor, or 
smaller than the floor. If the opening is larger, the ulcer is cup 01; 
basin shaped; if smaller, the margins are called undermined. Ver- 
tical or basin-shaped ulcers are found in non-infectious granulomata, 
neoplasms and those of chemical and thermal origin. Syphilis, too, 
may cause ulcers of this type. Nearly all ulcers with undermined 
edges are due to pyogenic organisms, the tubercle or Ducrey bacillus, 
central nervous disorders or gangrenes. The base of an ulcer dis- 
charges either serum, blood or pus, according to the etiology of the 
lesion, and the discharge is often foul. It tends to form crusts upon 
the removal of which, the presence or absence of granulation tissue in 
the floor, and the nature of the margins may be ascertained. Grad- 
ually progressive ulcers are called phagedenic. 

Cicatrices or scars are the result of healing when tissues deeper 
than the epidermis have been destroyed. They consist of fibrous 
connective tissue in which the hairs, glands and muscles of the skin 
do not regenerate. Nerves, however, and elastic tissue do reappear 
after months or years, and gradually the papillary body is formed 
anew. Young scars consist of organizing or organized granulation 
tissue; old scars of fixed connective tissue cells with fully developed 
connective tissue bundles. Young scars are abnormally vascular 
since scar tissue is the product of granulation tissue. The shape 
and size of scars depends upon the lesion of which they are the 



24 DEKMATOLOGY 

result. Scars are either flush with the skin, atrophied or hypertro- 
phied, according to the wealth of connective tissue produced. The 
last type is spoken of as a keloid or hypertrophied scar, but has 
nothing to do with true keloid which is a fibroma. The color of the 
scar depends upon its vascularity and pigmentation. Fresh scars 
are invariably reddish or bluish, fading in the course of time to white 
or flesh tones. If excessive pigment is formed, scars may be yellow- 
ish or brown. For the x most part scars are painless, but total an- 
algesia or hyperalgesia, though rare, are occasionally found. Large 
scars tend to contract, particularly those caused by burns or caustics, 
and if they are situated over joints may produce deformities, or if 
situated elsewhere cosmetic defects. 

Lichenification is a thickening of the skin caused by an increase 
in depth of the epidermis, and an infiltration in the papillary body 
and sub-papillary stratum. Clinically, it is characterized by an 
elevation of the skin, which is thick, hard and criss-crossed by exag- 
gerated cutaneous markings. It is the result either of scratching or 
rubbing in pruriginous diseases, such as scabies, dermatitis, prurigo, 
essential pruritis and senile itching dermatoses, Lichenified areas 
vary greatly in shape, size and outline. 

The color of skin lesions varies as already stated. The surfaces 
may be glistening, waxy, or dull, subject to the tension and charac- 
ter of the lesions. These are occasional alterations which will be 
described in connection with the diseases in which they occur. 
White lesions are rare excepting in exfoliative diseases, the scales of 
which are white. They usually result from loss of pigment. White 
spot disease, morphea, some of the idiopathic atrophies, syphilitic 
leucoderma, vitiligo, the peculiar whitish blue of argyria, and de- 
pigmented scars are examples. Psoriasis scales have a peculiar 
silvery tinge. Pink and red lesions are usually inflammatory, ex- 
cepting in nevi, and red tattooing. Yellow and orange lesions are 
found in xanthoma, and the former in some of the papules in lupus 
vulgaris, and in other tubercular lesions, vesicles, pustules and in 
some crusts. Favus scutula are sulphur colored and the crusts of 
impetigo and other serous exudations are golden. Buff character- 
izes many of the chronic dermatoses, as seborrhoea, some of the 
lichens, hyper-pigmentations and pityriasis versicolor. Brown 
lesions of all shades are due either to melanin or hemoglobin deriva- 
tives according to whether the disease is one of hyper-pigmentation, 
or due to hemorrhages. Nevi, melanomata and black tattooing fur- 
nish examples of the blue, slate and black lesions, while cyanoses and 



CONCEKNING CUTANEOUS LESIONS 25 

the blue lesions in body lice are examples of the various bluish tones. 
The later stages of lichen planus are violaceous, as are some nevi, 
and the latter may also be deep purple. 

The shape and configuration of lesions has already been partly 
touched upon. The simpler forms need no further mention. The 
following terms, however, circinate, gyrate, geographical and ser- 
piginous must be amplified. Circinate and gyrate lesions are formed 
usually by the coalescence of ringed and oval types, the peripheries 
of which, in merging, form a festooned outline. Gyrate lesions are 
formed by the merging of segments of circles of various sizes, differ- 
ing from the circinate only in the fact that the latter is made up of 
coalesced lesions of similar size. Serpiginous is a term often applied 
to ulcerated lesions tending to increase by the progress of a sinuous 
convex margin. This imparts to the lesions a fan or kidney shaped 
outline. Geographical lesions are extensive varieties, the shape and 
contour of which suggest the outlines seen in maps. 

Grouping. The shape and size of lesions have already been de- 
scribed. Their grouping and distribution come under the following 
general heads — localized, disseminated and generalized, symmet- 
rical and asymmetrical. These terms are self-explanatory, which is 
not the case however of the special designations, herpetic and corym- 
bose or corymbiform. Herpetic means resembling herpes. Herpes 
is a disease characterized by a cluster of vesicles in round, 
oval or slightly irregular patches of a diameter of from one half to 
two inches. Corymbose is a term applied to groups of lesions of 
which the central one is large and the surrounding ones small, a 
condition seen in syphilis when a large papule is surrounded by 
numerous small ones forming a group in which the central papule 
is the dominant feature. 

A few words as to the consistency of skin lesions will conclude 
this chapter. They may be soft or hard. Soft lesions may be 
flabby, boggy or doughy ; soft fibromata are examples of these lesions. 
Half emptied blebs or large pustules, cysts or abscesses are boggy 
or doughy. Hard lesions are elastic, brawny, stony or cartilaginous. 
Tense vesicles, pustules, blebs, cysts, etc., are elastic. Oedema may 
also be elastic or hard, when it fails to pit on pressure. Brawny is 
a term applied to the hard, inflammatory oedema seen in erysipelas 
and cellulitis. Stony hardness is observed in some fibromata, rhino- 
scleroma, keloids and hypertrophic scars. Cartilaginous consistency 
is found almost solely in the primary lesions of syphilis. 



CHAPTEE V 

METHODS OF EXAMINATION AND DIAGNOSTIC PROCEDURES 

The examination of dermatoses should be conducted in evenly 
distributed, soft, bright daylight. The patient should be stripped 
and the localization of the eruption, the character of the lesions, their 
color, distribution and consistency should be studied. Occasionally, 
there is objection to stripping, but all but very few patients finally 
acquiesce when they are made to realize that skin diseases frequently 
present different pictures on different parts of the body, and that in- 
telligent and conscientious conclusions cannot be reached without a 
comprehensive examination. All patients, particularly the prudish 
and those of unduly fine sensibilities, must be treated with the utmost 
tact. In general, less difficulty is encountered in private practice 
than in public clinics, for unwholesome modesty appears to be an 
attribute of the ignorant. After carefully looking at the lesions, 
palpation will determine their consistency, depth, the question of 
whether they are adherent to deeper parts, the presence of fluctua- 
tion, hyperemia, hemorrhages and sensitiveness. By scratching with 
the finger nail the character and adhesiveness of crusts and scales may 
be determined. It is more hygienic and infinitely safer to palpate 
with a finger protected by a finger cot, and to scratch with a curette, 
for the danger of acquiring syphilis must never be forgotten in der- 
matological practice. Unna's diascope, a piece of thick clear glass, 
may often be employed to advantage. It is used to exert pressure 
over lesions and render them ischaemic. Thereupon the lesion, as 
seen through the glass, can be studied without the confusing presence 
of blood in the dilated vessels. 

At the conclusion of the examination a detailed history should 
be taken. The illness for which the patient presents himself should 
first be taken up, beginning with the time and manner of its onset, 
the subjective symptoms, their development, and including any gen- 
eral symptoms which may have arisen. Then the clinical life his- 
tory should be investigated with reference to habits, occupation, 
mannerisms, appetite, diet, gastro-intestinal, genito-urinary, cardio- 
vascular, respiratory, nervous, venereal and any other diseases. 

26 



EXAMINATION AND DIAGNOSTIC PKOCEDUKES 27 

Changes in weight should be inquired about, as well as sleep, fatigue, 
working capacity and the psychic state. In many dermatoses it is 
of extreme significance to know whether drugs have been employed 
externally or internally, and whether cosmetics have been used. The 
family history should next be investigated. When this has all been 
done, the dermatosis should once more be examined, and a general 
physical examination should be made as carefully and thoroughly 
as possible. If necessary, other examinations by qualified special- 
ists should be made. To attempt a diagnosis in dermatology in any 
other manner is careless and inexcusable. Those who say that a 
diagnosis in this field should be made by the eye alone are not 
practicing scientific medicine, but are relying on a species of clever- 
ness which inevitably must often lead them astray. 

Besides the clinical methods of study just outlined, there are others 
often of great worth in clearing up obscure cases, or corroborating 
hypotheses. These are the laboratory methods. The lesions them- 
selves may be studied histologically, or scrapings or secretions from 
lesions may be examined under the microscope, or by various bacter- 
iologic procedures. Examinations of the blood, cerebro-spinal fluid, 
sputum, gastric contents, feces and urine, often aid in diagnosis, as 
do also some special tests. 

The value of the microscopic study of skin lesions is great. It 
often removes obstacles in diagnosis, and still more often enables the 
dermatologist properly to classify cases. Comparatively few der- 
matoses, it is true, possess a characteristic histologic structure, but 
enough do to make the help of the microscope distinctly valuable. 
Much may be gained, and certainly nothing lost, by invoking this 
aid in doubtful cases. The microscopic study of scrapings from 
lesions, affected nails, scales, fragments of hair, is done to determine 
the presence of animal parasites, bacteria or fungi. Secretions are 
studied for the same purpose, particularly to establish the diagnosis 
of primary syphilis by demonstrating spirochaetes. These facts will 
receive ample discussion in subsequent chapters. 

The detailed bacteriological study of dermatoses embraces all the 
methods employed in this field. The presence of micro-organisms 
in the lesions may be ascertained by suitable stains for spirochaetes, 
lepra bacilli, and other bacteria and fungi, as well as for Leischmann 
bodies in Delhi boil. The inoculation of guinea pigs in cutaneous 
tuberculosis is often of great value. The skin lesions of this disease 
are frequently poor in tubercle bacilli, and animal inoculation with 
suspected tissue may facilitate a diagnosis when other methods fail. 



28 DERMATOLOGY 

With increasing precision of technique a similar method will prob- 
ably prove valuable in syphilis. The testes of rabbits are peculiarly 
vulnerable to spirochaetes, and suspected tissue or secretions injected 
into these organs frequently cause the local development of a 
syphilitic granuloma. Cultivation, on suitable media, of micro- 
organisms from scrapings^ secretion and scales of lesions and from 
suspected hairs and nails, frequently aids in diagnosis. Sabouraud 
has devised a special medium for the cultivation of ring-worm organ- 
isms and allied fungi. The various pus producing organisms luxur- 
iate on ordinary media. 

An examination of the blood includes the ordinary hemoglobin 
and cytological estimations ; blood cultures, complement fixation tests 
and chemical analyses. The blood count may reveal an anemia, 
leukemia, or some other disease or disturbance, the successful regu- 
lation of which will favorably affect dermatoses. In addition, sev- 
eral dermatoses influence the blood picture. Erythema nodosum, for 
example, is often associated with secondary anemia. Syphilis, too, 
causes anemia and a leukopenia with relative lymphocytosis. Toxic 
dermatoses are often accompanied by a mild leukocytosis, with an 
increase of the polymorphonuclear leukocytes. In erysipelas this 
is particularly the case. Eosinophilia is common in itching dis- 
eases, particularly in scabies, prurigo, pemphigus and dermatitis 
herpetiformis. Blood cultures have not been found to be of great 
value in dermatology, excepting in dermatoses due to sepsis. Com- 
plement fixation tests have been employed in syphilis, blenorrhagic 
granuloma and ring-worm. Of these, only the first, the Wassermann 
test, is of great practical value. The gonococcus complement fixa- 
tion test of Hans Schwartz may be of use in the recognition of 
blenorrhagic dermatoses. Work has been done indicating the pres- 
ence of the Bordet-Gengou reaction in ring- worm, which although of 
great scientific interest, is superfluous as a diagnostic procedure, for 
the condition is easily recognized by simpler means. Chemical 
studies of the blood may be performed with reference to sugar, 
cholesterin and nitrogen metabolism. Their purpose is to determine 
the etiology of skin diseases, rather than to simplify diagnosis. An 
increase of blood sugar has been found in pilosebaceous diseases. A 
cholesterinemia is present in xanthoma tuberosum. Very little work 
upon the nitrogen content of the blood has been done in dermatology. 
Excepting in syphilis, analysis of the cerebro-spinal fluid has no 
value. 

Examination of the sputum for tubercle bacilli is often of great 



EXAMINATION AND DIAGNOSTIC PROCEDURES 29 

value in corroborating a diagnosis of cutaneous tuberculosis. The 
organisms causing Vincent's angina and syphilis may also be found 
in this secretion, but are more easily demonstrable in scrapings from 
suspected lesions. Examining secretions from the rhinopharynx for 
Hansen bacilli is occasionally of diagnostic value in suspected lepra. 

Studies of the gastric contents and feces will often show the exist- 
ence of some type of digestive disturbance, which may be the basis 
of given dermatoses such as acne, seborrhoea, rosacea, urticaria or 
dermatitis. Qualitative and quantitative urinalyses may be of sim- 
ilar service, particularly in diabetes which often provokes dermatitis 
and furunculosis. A disturbed nitrogen metabolism, ascertained by 
quantitative urinalysis, may be the determining factor in psoriasis, 
prurigo, dermatitis and dermatitis herpetiformis. 

The special tests alluded to are the various tuberculin tests, the 
luetin reaction and a percutaneous test in the sense of Pirquet for 
ring-worm and allied diseases. The tuberculin tests are performed 
by the hypodermatic, percutaneous and cutaneous application of 
tuberculin. The first method was discovered by von Pirquet and 
bears his name ; the cutaneous test was devised by Moro. The luetin 
test, based roughly on Pirquet 7 s technique, was devised by Noguchi, 
and a similar test for trichophytosis was first employed by Bruno 
Bloch of Basel. All of these tests will be fully discussed in their 
proper places. 

It is apparent from these paragraphs that the analysis of a 
dermatological case involves all of the principles of internal medical 
examination. A good history is essential. A careful inspection of 
the skin, as well as a general physical examination of the patient, 
must be made. Proper laboratory work must be carried out. The 
dermatologist should not only be a clinician, but also a histo and 
clinical pathologist, bacteriologist and chemist, in the sense that he 
must know how to interpret the findings in these special fields of 
medicine. 



SECTION B. PUKE DEKMATOSES 



GEOUP I. CUTANEOUS REACTIONS DUE ESSEN- 
TIALLY TO VASCULAR DISTURBANCES 

CHAPTER VI 

THE ERYTHEMAS AND URTICARIA 

The important part played by the cutaneous vessels is the common 
and striking feature of this group of diseases, nor is it anatomical 
vascular changes so much as mechanical ones with which we have to 
deal. Vasodilatation, primarily, or after spastic constriction, is the 
starting point of these dermatoses. The causes of such vascular 
instability are numerous and may be arranged under four heads — 
organic, physical, reflex nervous (so called), and toxic. The organic 
causes are mainly chronic cardiovascular, respiratory diseases and 
personal peculiarities causing erythemas and cyanoses, due to changes 
in the calibre and tone of vessels. Blue fingers and ears, blushing 
and flushing are examples. These are scarcely cutaneous lesions 
but are significantly related to such. Physical causes are 
pressure, heat, light and cold. Reflex nervous causes are exciting 
psychic disturbances and the neuropathic states associated with denti- 
tion, menstruation, gestation and the menopause, while the toxic 
causes include ingested toxins and those due to metabolic derange- 
ments. The former are introduced into the body as food or medi- 
cines; the latter are manufactured in the body as the result of in- 
digestion, disturbances of internal secretions controlling digestion or 
elimination, biochemic changes connected with nephritis, diabetes 
and the cachexias. Even the reflex nervous causes may be due to 
the conditions just mentioned influencing the nervous system, rather 
than to the nerves, per se. Thus, a reflex disturbance during the 
menopause may not be functional so much as due to a possible 
endocrine disturbance or a toxin elaborated during this period. 

The common symptoms of this group of skin diseases are itching, 
and the presence of red macules. The macules may remain as such, 
or develop into papules, nodules, ulcers, vesicles, bullae, or leave 
hyperpigmentation. The diseases may be acute or chronic, trans- 
itory or persistent, but they are all emphasized at the beginning by 
redness of the skin, excepting urticaria which starts with white 
lesions quite as often as with red. 

The erythemas occur in three important anatomical forms, the 

33 



34 DEKMATOLOGY 

diffuse, macular aud nodular, represented respectively by the im- 
portant conditions known as erythema scarlatiniforme, erythema 
exudativum multiforme, and erythema nodosum. 

ERYTHEMA SCAKLATINIEORME 

Synonyms. Scarlatinoid Erythema; Desquamative Scarlatinoid 
Erythema ; Scarlatinoide ; Erythema Punctatum ; Roseola Scarlatini- 
forme; Dermatitis Exfoliativa Acuta; Erythema Scarlatiniforme 
Desquamativa Recidivans; French; Erytheme Infectieux. 

Definition. Scarlatiniform Erythema is an acute or subacute 
disease of the skin characterized by a generalized punctate scarlet 
eruption, which runs its course in from a few days to three months 
and which is prone to recur. It is usually accompanied by mild 
systemic disturbances. 

Symptoms. The acute form has a sudden onset accompanied by 
malaise, prostration and a rise in temperature which occasionally 
reaches 104° E. The rash appears within a few hours, may remain 
localized, but usually involves the whole body surface with punctate 
scarlet macules. The pharynx is uniformly red, but the throat and 
tongue do not resemble those of scarlatina. Within a few days the 
temperature is again normal and a fine furfuraceous scaling takes 
place. There are no complications or sequelae. 

The subacute form also begins suddenly in a manner similar to 
the acute, but it runs a longer course lasting from two to three months. 
The onset is at times accompanied by gastro-intestinal disturbances. 
The character of the rash resembles that of the acute form at first, 
but the redness persists and the desquamation is coarse, the scales 
having a diameter of from 1% to 5 cm. The pharynx and con- 
junctivae are reddened. Torok mentions the occasional presence of 
lymph adenopathies. Recurrences are frequent. In both forms 
itching, either mild or severe, is present. 

Etiology and Pathogenesis. The etiology is not clearly under- 
stood. The disease may be idiopathic or secondary to other diseases 
or medicaments. Of the diseases, sepsis, abscesses, and toxemias of 
all sorts are the most important; of the medicaments, serum injec- 
tions, tuberculin, mercury and salvarsan are to be considered. 
Arsphenamin needs especial emphasis because of its wide use. 
A few individuals are either born with, or acquire an intolerance to 
this substance, one of the manifestations of which is the subacute 
scarlatinoid erythema, at times attended with alarming systemic 
manifestations such as suppression of urine. 



THE ERYTHEMAS AND URTICARIA 35 

Differential Diagnosis. Scarlatina, the chronic erythrodermas, 
universal exfoliative dermatitis, and generalized psoriasis are the 
diseases from which this one must be distinguished. The most im- 
portant of these is scarlatina. In the latter the early symptoms are 
severer, the throat and tongue are characteristic, there is a pale zone 
about the mouth, the fever curve is typical and there are no recur- 
rences. 

Treatment. During the exanthematous stage the patient should 
be in bed on a fluid or semisolid diet. At the start a saline cathartic 
is to be given and the bowels throughout the disease are to be kept 
open by means of cathartics or enemata, and above all by a suitably 
balanced diet. Should the itching be intense, mild sedatives, 
chiefly bromides, are indicated, but it must be remembered that in 
some people these themselves provoke itching. Should an underly- 
ing cause be determined, the treatment must be directed towards its 
elimination. Locally, the indications vary according to the stage of 
the eruption. At the onset soothing lotions must be used, such as 
calamine or calamine and zinc, or a menthol and camphor spray sev- 
eral times daily. Should the patient be unable to stand the exposure 
and chilliness the use of fluids involves, powdering with zinc stearate 
is useful. Under no conditions should an ointment be used as this 
may irritate the skin. Occasionally, however, a zinc paste may be 
employed. During the stage of exfoliation a ten percent, zinc salve 
or simple emolient cream should be gently applied once or twice a 
day. 

Prognosis. The prognosis is good. 

EEYTHEMA MULTIFORME EXTTDATIVUM OF HEBRA (FIG. 1) 

Definition. Erythema Exudativum is an acute disease charac- 
terized by the sudden appearance on the backs of the hands, and 
insteps, and neck behind the angles of the jaw of vivid red or pur- 
plish macules or papules. 

Symptoms. The onset of the disease is acute with or without 
systemic symptoms. An eruption of red, bluish red or purplish 
macules first appears on the dorsal surfaces of the hands, (Tig. 1) 
feet and neck behind the jaw. Next the extremities and face are 
involved, and in some cases the entire body. The macules vary from 
the size of a lentil to a quarter, and may turn into papules raised 
about y$ inch, which are elastic and resistant to the touch. At the 
onset there may be fever reaching 103° F., malaise and prostration, 
and at the same time pharyngitis and arthralgias are often encoun- 



36 DERMATOLOGY 

tered. The conjunctiva was involved in three quarters of the cases 
observed by Duhring, fever in thirty percent, of the cases, cervical 
gland and splenic enlargements in a few. Duhring regards/the con- 
junctivitis, fever, malaise and occasional anorexia as prodromata. At 
times severe itching or burning are present, and occasionally lesions 
are found upon the buccal mucosa. 

Course. The disease usually lasts from a fortnight to a month. 
At times there are recrudescences and in many individuals recur- 
rences. Complications are exceptional. 

Varieties. 

Although the typical form is characterized by macules and papules 
which remain discrete, there are also cases in which a coalescence of 
the lesions takes place giving rise to erythema annulare or circinatum 
and figuratum. At times, too, the form of the lesion is modified and 
we have erythema papulatum or papulosum, tuberculosum, vesicu- 
losum, bullosum, and urticatum. These designations simply indi- 
cate the clinical varieties the disease may assume, but are not sepa- 
rate diseases. The term erythema urticatum denotes the severity of 
the pruritis. 

One variety, however, merits special mention. This is erythema 
iris, also called herpes iris. Its localization and course correspond 
to those of the ordinary form from which it differs only in appear- 
ance. This difference is due to two factors. The first is the pres- 
ence of a central vesicle surmounting a hyperemic base and this base 
tends to extend peripherally pushing the hyperemic zone ahead. 
With the peripheral extension central involution takes place. At the 
periphery a new vesicle forms which is ring-shaped. Thus, a target- 
like figure of several rings is formed, the outermost in the process of 
evolution, the inner ones in the course of recession. These concen- 
tric rings are the second characteristic point. 

Differential Diagnosis. Erythema Multiforme should, but 
cannot always be distinguished from erythema toxicum and 
urticaria, to both of which it is closely related, and from pellagra; 
while the vesicular and bullous varieties must be differentiated from 
dermatitis herpetiformis and pemphigus. The toxic erythema 
lesions are paler, do not necessarily occur first on the backs of the 
hands and feet, and usually remain macular assuming the various 
figures described in the exudative form. The differentiation from 
urticaria rests on the absence of wheals, in erythema multiforme and 
the less intense itching. Its difference from pellagra, dermatitis 
herpetiformis and pemphigus will be considered with those diseases. 



THE EEYTHEMAS AND URTICARIA 37 

Etiology and Pathogenesis. The etiology is obscure. The 
disease is found more often in men than women, and mostly in young 
adults. It seems to favor the Spring and Fall and at times it 
occurs in epidemics as noted by Duehring. It bears a distinct rela- 
tion to digestive and metabolic disturbances and to rheumatism, but 
there is possibly a type due to a specific infection. Hebra first 
noted intestinal disturbances. Freund found evidences of proteid 
putrefaction in studies of the urine. Mracek corroborated this by 
determining the beneficial effects of intestinal antiseptics. It has 
been found associated with nephritis, diabetes and tuberculosis. 
Thus, it is either secondary to or associated with visceral diseases, 
in the sense of Osier, or infectious diseases. Drugs, and particu- 
larly sera, may cause lesions of this type. Mackenzie noted its 
relationship to purpura and rheumatism. 

Treatment. The treatment is internal and local. The princi- 
pal indications for internal therapy are dictated by the possible 
relationship of the disease to intestinal indigestion and rheumatism. 
As to the former, vigorous catharsis induced by calomel and salts, 
and intestinal lavage in the form of daily colon irrigations will 
suffice. Salol, ichthyol, small doses of phenol, internally admin- 
istered for purposes of antisepsis are useless. By far the most 
important factor is diet. Analyses of the gastric contents and stools, 
particularly the stools, in conjunction with the presence of indol and 
skatol in the urine, indicating a proteid putrefaction, will serve as 
guides for prescribing a proper diet. In such cases the use of 
lactic acid bacilli may be of value. When associated with rheuma- 
tism, the treatment of this condition is the one of paramount im- 
portance. This involves eliminative treatment and the administra- 
tion of salicylates, an excellent vehicle for which is rhubarb and 
soda mixture. The local indications are determined by the pathology 
of the disease. It is a vascular dilatation probably due to a tem- 
porary paresis of the vessel walls, or the first stage of a mild acute 
exudative infl amm ation.. Calamine or calamine and zinc lotion 
applied several time daily will answer all requirements. Oint- 
ments and pastes are useless. For severe itching the menthol spray 
and the judicious use of sedatives will prove of great value. 

Prognosis. The prognosis is good. 

ERYTHEMA NODOSUM (FIG. 2) 

Synonyms. Erythema Contusif orme ; French, Erytheme Noueux. 
Definition. Erythema Nodosum is an acute disease character- 



38 DERMATOLOGY 

ized by systemic symptoms and the sudden development on the shins 
and forearms of tender, painful, red infiltrations or nodules. 

Symptoms. Accompanied by mild prostration and a fever of 
from 100° to 10±° F., the eruption appears suddenly on the shins 
(Fig. 2). It consists of painful, bluish red nodules varying in size 
from that of a lentil to a robin's egg. The lesions resemble bruises 
(Fig. 2) ; hence the name erythema contusiforme. The extensor 
surfaces of the forearms toward the ulnar side, and finally the ex- 
tensor aspects of the thighs and arms, even though only rarely, may 
be involved. Most commonly the disease remains localized to the 
shins. The lesions are exquisitely tender and never break down. 
They disappear without trace. 

Course. Within from a fortnight to three months the disease 
disappears, frequently leaving the patient with a secondary anemia. 
Recurrences are most exceptional, although the malady is often 
associated with rheumatism. Occasionally erythema nodosum and 
erythema multiforme appear together. 

Differential Diagnosis. Erythema nodosum must be differen- 
tiated from erythema indurativum of Bazin, and syphilitic perios- 
teal gum mat a involving the skin above and known as erythema 
nodosum syphiliticum. Bazin' s disease is tuberculous in origin, 
and since erythema nodosum is also widely regarded as associated 
with tuberculosis, it may readily be seen that a differentiation 
between the two conditions may prove difficult. Erythema nodosum, 
however, never ulcerates, or leaves any traces after disappearing. 
Bazin's disease usually does ulcerate, leaves scars and recurs, and 
finally is nearly always present in connection with other evidences 
of tuberculosis. In doubtful cases animal inoculation and histo- 
logical studies will clear up the question. The simple form of 
erythema nodosum is distinguished from the syphilitic form by 
the fact that the latter tends to break down, recurs, and is improved 
by anti-syphilitic treatment. The Wassermann test is positive. 

Etiology and Pathogenesis. Some authors consider it rheu- 
matic and a form of erythema multiforme, while others, notably 
Hebra and Jadassohn, regard it as a distinct clinical entity, a view 
which to-day is generally accepted. It is known in many instances 
to follow measles and malaria, and to be associated with sepsis, bac- 
terial endocarditis and tuberculosis. It is generally regarded as 
rheumatic in origin, but recently an extensive study of the disease by 
Foerster indicates at least an intimate association with, if not a 
causative relation to tuberculosis. This seems true to a larger 



THE ERYTHEMAS AND URTICARIA 39 

extent among children than adults. Rosenow isolated a specific 
diplo-bacillus from the lesions. It is evident that there are etiolog- 
ically two groups of the disease — one associated with rheumatism 
and the other with tuberculosis and measles; and finally, if Rose- 
now's work is correct, there may be a third specific form. Women 
seem more prone to the affliction than men, and although it may 
occur at any age, children and young adults seem to be most suscep- 
tible. Bass reported a case associated with orchitis in a 2% year 
old boy. The majority of cases occur in the Spring and Fall. 

Treatment. The treatment is internal and local. The internal 
treatment is directed toward the associated condition which is either 
rheumatism or tuberculosis. The local treatment has two objects — 
first to relieve the pain and tenderness, second to alleviate the inflam- 
mation. Wet dressings fulfil these indications. Aluminium acetate, 
diluted with ten parts of water and changed every half hour, is ex- 
cellent. It is wise, in order to facilitate evaporation, not to cover 
the dressings with rubber tissue or oil silk. The evaporation in- 
creases the relief of pain and hastens the reduction of the inflam- 
mation. Some patients prefer warm or hot wet dressings. As an 
adjuvant to the fomentations calamine lotion should be used. In 
cases followed by secondary anemia, this special indication must 
be met. 

Prognosis. The prognosis is in the main excellent, although in 
some of the cases apparently associated with tuberculosis, the out- 
look is poor, but in these cases the prognosis becomes that of the 
tuberculosis and not of the erythema. 

TOXIC EKYTHEMAS 

Toxic erythemas are due to toxins ingested or resulting from dis- 
turbed metabolism or some general disease. The former are due 
to drugs or tainted foods; the latter are due to indigestion, infec- 
tious diseases, particularly sepsis and bacterial endocarditis. They 
are characterized by the presence of pink, pale or deep red circular or 
oval macules, which may coalesce into circinate, gyrate or figured 
lesions. They are evanescent and recurrences are frequent while the 
etiological factor persists. 

PHYSIOLOGICAL ERYTHEMAS 

Two types of erythemas must be mentioned, which though not 
pathological, must be understood. They are the cutis marmorata 
and the roseola infantilis. 



40 DERMATOLOGY 

Cutis M anno rata means marbled skin. When patients are ex- 
posed to cold air, some of the superficial vessels dilate, giving to 
the entire skin the striated appearance seen in marble. This must 
be borne in mind in examining for the syphilitic roseola. In 
marbled skin there is a tracery of delicate irregular red lines sep- 
arating the normally colored patches which are round. In the 
specific roseola, the lesions are red and round or oval, and divided 
by a delicate lace-work of normally colored skin. 

The Roseola Infantilis known in German as the " Schrei Exan- 
tli em " is seen in babies when the effort of crying causes the cutane- 
ous vessels to distend. This develops on the skin a punctate rash 
resembling that of scarlatina, measles or German measles. It van- 
ishes when the infant is again quiet. 

Other erythemas are Erythema Hyperemicum or Simplex, which is noth- 
ing but a blush and is caused by excitement; Erythema Caloricum, caused 
by extremes of temperature; Erythema Solare, caused by Finsen, Roentgen 
or sun's rays; Erythema Gangrenosum , a rare disease starting with ery- 
thematous spots and ending with gangrenous nodules ; Erythema Laeve, the 
shiny red erythema of the legs in infants with cardio-vascular and renal 
disease; Erythema Fugax, an adjective indicating evanescence; Erythema 
ab Igne, a rare gyrate reticulated disease of the anterior surface of the 
legs, leading to permanent pigmentation and found in senile, weak or 
alcoholic individuals exposed to intense heat (firemen, stokers) ; Erythema 
Symptomaticum seen before acute infectious diseases, or following vaccina- 
tion, or vascular, cardiac or vasomotor diseases; Erythema Infantum of 
Escherich, an epidemic erysipeloid disease of children from four to ten 
years old; and Erythema Elevatum Diutinum, a rare disease of the extensor 
surfaces seen in children and young adults and allied to granuloma an- 
nulare. Finally, there is Erythema Intertrigo or intertrigo, a reddening of 
the proximate surfaces of skin in body folds, predisposed to by heat, 
moisture and irritation. This probably belongs to diseases of the derma- 
titis group. 

A rare, though important syndrome in this group, is Erythema 
perstans. In this disease, sometimes fading and again developing, 
always at precisely the same sites are discoid macules. Their size 
at times equals that of a nickel or quarter. In color they range 
from red to purple. They may itch. There may be few or a rela- 
tively great number of lesions, and there are two groups; one in 
which the cause may be ascertained, another in which it cannot 
be. In the former it is usually drugs that are the cause, notably 
antipyrin and its allies, and phenolphthalein, as in cases reported 
by Abramowitz and Howard Fox. In rat bite fever this form of 



THE ERYTHEMAS AND URTICARIA 41 

erythema is strongly suggested. The treatment consists in elimi- 
nating the known cause, and otherwise in a regimen similar to that 
considered effective in other forms of erythema. It is usually fruit- 
less to treat the disease unless its etiology is determined. The 
prognosis is always good as to general health, and never so as to a 
cure, unless the etiology is discovered. These factors also decide the 
course. At times lupus erythematosus disseminatus arises appar- 
ently as an erythema perstans; the true nature of the disease 
revealing itself under prolonged observation. 

URTICARIA (FIG. 3) 

Synonyms. Nettle rash; German, Nesselsucht, "Nesselfieber, 
Nesselausschlag ; French, Urticaire, Ortie. 

Definition. Urticaria is an acute disease, usually running a 
short course, and characterized by the sudden appearance, without 
definite localization, of peculiar and intensely itching raised lesions, 
which at first are white and subsequently become red. 

Urticaria includes angioneurotic edema, is closely related to 
prurigo and remotely allied to the so-called urticaria pigmentosa. 
The characteristic feature of urticaria is the wheal, a raised, white, 
tense, edematous lesion, the best example of which is a fresh mosquito 
bite. The wheal is due, according to Unna, to vascular spasm and 
a serous transudate, which accounts for its whiteness. When the 
spasm is relieved the vessels dilate and the wheal becomes a pink 
or red raised lesion, difficult to distinguish from that of erythema 
multiforme. According to Sczamberg of Prag, it is due to a hyper- 
secretion in the cutaneous lymphatics. 

Symptoms. The onset of the disease is sudden. Within a few 
moments or hours the body is covered with wheals of all sizes from 
that of a lentil to that of a dollar. They may combine into circin- 
ate, gyrate and figured groups, or, extending peripherally, may be- 
come annular. The freshest lesions are of a distinctive white re- 
sembling porcelain ; the older lesions are red. As a rule, a mixture 
of the two is present by the time a physician is consulted. Often 
systemic disturbances such as nausea, diarrhoea, headache, malaise 
and fever accompany the outbreak, or it follows a prolonged period 
of constipation. The itching is usually furious, causing the patient 
to be agitated and constantly to rub or scratch the lesions. On 
stroking the skin a wheal develops, the form of which is linear or 
curved, according to the direction of the artificial trauma, and it 
is possible even to make figures or form letters on the skin in this 



42 DERMATOLOGY 

manner. This phenomenon is known as urticaria factitia or 
dermographism, and is diagnostic of urticaria. At times the 
pharyngeal and buccal mucosa are the site of lesions. In fading, 
the wheals leave either no trace, or pinkish spots that last a few 
days, or hvperpigmentation if the lesions have been persistent, or 
the transudate has contained blood. When loose skin, such as that 
of the evelids, is involved, actual local edemas arise. 

Course. Within a few hours to a week the disease is usually well. 
There are, however, prolonged cases in which the patient is the 
victim of a series of such attacks, the itching and annoyance of 
which interfere with his rest, and thus weaken him as much as a 
graver disease might. 

Varieties. 

Many of the varieties are due to accidents of arrangement, as 
Urticaria Annularis and Gyrata, or to peculiarities of involution as 
Urticaria Evanida (rapid) or Urticaria Perstans (slow). A rare va- 
riety is Urticaria Solitaria, a single recurrent type described by 
Vomer. More important are Urticaria Vesiculosa, Bullosa, Papu- 
losa, Tuberosa and Hemorrhagica. The terms are self-explanatory. 

Urticaria Papulosa begins in the ordinary way, but some of the 
wheals are converted into papules forming a link with prurigo and 
papular dermatitis. 

Urticaria Tuberosa or Giant Urticaria is a form of the disease 
entity known as angioneurotic edema, which will be discussed below. 

Urticaria Hemorrhagica depends for its development upon the 
presence of blood in the exudate and connects urticaria with the 
purpuras. 

Urticaria Vesiculosa and Bullosa are varieties in which the 
exudate is excessive and serum accumulates below the epidermis. 
The bullae may be as large as a robin's egg. These forms connect 
urticaria with erythema bullosum, dermatitis herpetiformis and 
pemphigus. 

Differential Diagnosis. The three salient points upon which 
the diagnosis of urticaria rests are the characteristic wheal, the 
presence of dermographism and the intense itching. Upon these 
points it must be distinguished from erythema multiforme as already 
discussed under that disease; and from dermatitis herpetiformis, 
pemphigus and papular dermatitis, the differential points of which 
will be taken up subsequently. 

Etiology and Pathogenesis. The causes of urticaria are exter- 
nal and internal. The external ones are irritants, as insect and jelly 



THE ERYTHEMAS AND URTICARIA 43 

fish stings and poisonous vegetables, such as the nettle. Changes in 
environment and climate also cause urticaria, and the bullous type 
particularly, develops after a sea voyage to a foreign country. The 
internal causes are toxic and nervous. 

I. Toxic Causes. 

A. Foods : Eggs, roe, fish and Crustacea, bivalves, dried fruits, flesh 

of poultry and mammals, particularly pork and sausage, cheese, 
cereals, peas, beans, lentils, corn, mushrooms, nuts, tea, coffee, 
cocoa, alcohol, strawberries, cucumbers, onions, garlic, pickles, 
pastries, honey and sweets. 

B. Drugs: Sera, antitoxins, vaccines, quinine, copaiba, sandal wood 

and other balsams; to a lesser degree, opium and its derivatives, 
hyoscyamus, chloral, the salicylates and arsenic. 

C. Diseases due to Animal Parasites: Plasmodia, intestinal amoebae 

and worms, and echinococcus cysts. 

D. General Diseases: Metabolic, gastro-intestinal and eliminatory 

disturbances. 

E. Sequelae or Complications of other Diseases: Asthma, pemphigus, 

variola, etc. 

II. Nervous Causes. 

Kreibich and Sobotka in studying the effect of emotions on vasomotor 
disturbances concluded that these caused some forms of urticaria. 

Thus urticaria has been ascribed to a wide and apparently un- 
related series of causes. Upon further analysis, however, they are 
found to hang together relatively coherently, and to operate accord- 
ing to very simple principles. Urticaria is regarded as an anaphy- 
lactic phenomenon, clearly due in the majority of instances to a 
toxic protein. Some substances, though, which cause urticaria are 
clearly not protein. The problem is to bring these two groups, as 
well as the influence of the nervous system, into harmony. Before 
discussing this, let us revise our etiological classification on the 
basis of two groups of toxins — the protein and the non-protein. 

Group I. Protein Toxins. 

A. Animal Proteids : 

1. Ingested: Egg albumin, milk, cheese, flesh of mammals, birds, 

fish, Crustacea and bivalves, etc. 

2. Otherwise Introduced: Sera, including antitoxins. 

3. Animal parasites or their metabolic derivatives: vermes and 

protozoa. 

B. Vegetable Proteids: 
1. Ingested : 

a. E'ood: Peas, beans, lentils, cereals, mushrooms, nuts, straw- 



44 DEBMATOLOGY 

berries, cucumbers, pickles, onions, garlic, corn, honey, tea, 
coffee, etc. 
b. Medicaments: The balsams, opium and its derivatives, quinine, 
and hyoscyamus, etc. 
2. Otherwise Introduced: Drugs, sera and vaccines. 

Group II. Non-Protein Toxins. 

1. Ingested : 

Medicaments : Salicylates, the coal tars and arsenic. 

2. Otherwise Introduced: Medicaments, mercury and arsenic, chiefly 

arsphenamin. 

The symptoms of anaphylaxis in man are less severe than in 
animals used for experimentation. A salient feature is urticaria, 
another is asthma, a third is eosinophilia. The way in which 
the reaction is determined is by the union of the toxin by means 
of amboceptors or without them, to the body cells. This being 
the case, the action of the non-proteid toxins which provoke urti- 
caria is explicable in one of two ways. They either are similar 
to the proteid toxic molecules and thus have similar affinities, or 
they cause chemical changes in the body proteids so altering these 
as to render them capable of similar behavior as toxic entities, 
or of altering the cells themselves rendering them hypersusceptible. 
This explanation, too, would account for the role played in the 
process by metabolic diseases, and disturbances of digestion and 
elimination, as well as the cases associated with or following asthma, 
small pox, pemphigus, etc. 

In metabolic diseases substances unusual as to composition or 
quantity are produced, and must be either proteid or non-proteid 
in character. Their behavior would be subject to the scheme out- 
lined above. The same is true of diseases of elimination which 
cause the retention of substances promptly excreted in health. In 
digestive derangements the manner of intoxication may he two-fold, 
either by the production and absorption of abnormal substances, or 
by an alteration of intestinal permeability favoring the absorption 
of substances usually present, but not assimilated in health and 
which, when absorbed, become pathogenic. Proteid putrefaction is 
frequently an associated condition, an indicator of which is indi- 
canuria which, in older days, was itself considered a cause of urti- 
caria. Asthma, as already mentioned, is a symptom of anaphylaxis ; 
and pemphigus, variola, etc., would cause urticaria in the manner 
suggested under disturbances of metabolism and elimination. 

The pathogenic role of the nervous, preeminently the sympathetic, 
system has been already touched upon. It may be immediate, and 



THE ERYTHEMAS AND URTICARIA 45 

act simply by means of increasing vascular instability, or mediate, 
and act by altering metabolism, elimination or digestion, in which 
case the explanation of this phase of the problem is along the lines 
laid down in the previous paragraph. The reflex nervous mani- 
festations associated with dentition, menstruation, gestation, lac- 
tation and the climacteric would come under this head, when 
urticaria is a concomitant condition. As a corollary to this the 
endocrine mechanism would participate in the process. 

Among those subject to urticaria the minutest quantities of patho- 
genic substances, as one strawberry, a trifle of egg albumin, or a 
drop of quinine solution will suffice to excite an attack. Immunity 
does not develop in these patients, but may be artificially produced, 
as Schloss has shown in his ingenious and remarkable study on 
egg albumin urticaria. 

The manner in which the external causes of the disease operate 
remains to be considered in connection with anaphylaxis. In 
Schloss' s case attacks were provoked when the egg albumin reached 
the patient's lips, even before he swallowed it. On one occasion, 
when the child merely played with an egg shell to which some of 
the white had adhered, he had a seizure. In other words, a high 
degree of sensitization was present. This is the probable way in 
which all local irritants operate. Cases following sea voyages and 
changes in surroundings are probably in the metabolic and diges- 
tive groups. 

The Mechanics of the Urticaria Lesion: The toxin causes primarily a 
spasm of the cutaneous vessels, according to Unna, the veins. Whether 
this is due to a direct effect on the vessel by means of stimulation of the 
vaso-contraetors, is not important. Because of obstructed return circula- 
tion, a serous transudate forms locally exerting further pressure on the 
vessel originally involved, as well as on its neighbors. Thus, a small area 
is made ischemic. This explains the whiteness of the wheal. As the 
vessel relaxes and the local circulation is re-established, the wheal fades. 
Often no trace remains. Frequently, however, a slight local inflammation 
persists, due to vascular dilatation and congestion after the spasm. When 
the exudation is extensive a vesicle, bulla or papule forms. The histo- 
pathological features need not be mentioned. Other factors in the pro- 
ductive mechanism of the disease are diminished blood coagulability, in- 
creased permeability of the vessel walls and increased irritability of the 
muscles and nerves of the vessels, all of which are phenomena admittedly 
related to anaphylaxis. Sczamberg, as already mentioned, ascribes the 
wheal to sudden oversecretion in the cutaneous lymphatics — in other 
words to an acute local lymphedema. 

Treatment. The treatment of urticaria is prophylactic and 



46 DERMATOLOGY 

actual. "When it is definitely known that certain foods or drugs 
in given individuals cause urticaria, they must be avoided. Thus, 
a careful history of every case is necessary, in the first place to 
rule out the simpler etiological factors, and in the next to discover 
digestive, metabolic or nervous causes which might favor the attack. 
The actual treatment is internal and external; the object of the 
former being to eliminate the toxin, of the latter to lessen the itching. 

The inteexal treatment should consist of catharsis, and diure- 
sis. Calomel and salts, or salts alone, followed for a few days by 
mild vegetable cathartics such as rhubarb or cascara will usually suf- 
fice. In obstinate cases, and in those presenting a history of constipa- 
tion, or in those in which proteid putrefaction is ascertained by 
examining the stools, suitable diet should be prescribed, and colon 
irrigations, the administration of intestinal antiseptics, such as salol, 
ichthyol, small doses of phenol, or cultures of the Bulgarian ba- 
cillus. Of these the colon irrigations are the best. Diuresis should 
be caused by an increased ingestion of fluids and the use of diuretics. 
Sudorifics and hot packs, to produce cutaneous elimination, are 
contra-indicated, since the irritable skin will tolerate them poorly. 
Calcium lactate in massive doses, three grammes before breakfast, 
is of benefit in many cases. This treatment is based upon Kastle, 
Healy and Buckner's work. Calcium lactate not only tends to over- 
come anaphylactic shock, but calcium and its salts are supposed to 
decrease the permeability of vessels, increase blood coagulability 
and quiet the nervous system. Alkalies, atropin, the bromides and 
other sedatives are used to meet special indications, actual or the- 
oretical, but are of little value. In many instances the hypoder- 
matic injection of suprarenal gland extract causes immediate and 
permanent relief. Recently, in obstinate cases, autoserum admin- 
istration has been employed, but the results are inconstant and 
the advocates of the treatment unconvincing. The only rational 
treatment in obstinate cases would be to determine the etiological 
factor or factors and artificially immunize the patient along the 
lines suggested in Schloss's work. This, however, would be difficult 
in most instances and necessary only when the intolerance exists 
towards important foods and drugs. 

The local treatment includes the use of lotions, powders, 
washes, baths and ointments. Calamine or calamine and zinc lotion, 
with one percent, of phenol or menthol, or five percent, of ichthyol, 
applied several times a day, or mentholated powders made with zinc 
stearate, zinc oxide, bismuth or talcum often give immediate and 



THE ERYTHEMAS AND URTICARIA 47 

permanent relief. Washes, consisting of one percent, menthol or 
phenol in equal parts of alcohol and rosewater, either sponged on 
the itching points or sprayed on with an atomizer, may he employed 
in addition to the lotions and powders. One of the old household 
remedies, bicarbonate of soda in water, often does good. Bran 
baths at the patient's favorite temperature, or soda baths are very 
useful. The patient, when drying after his bath, should be cautioned 
not to rub vigorously, but rather to use the towel as a sort of 
blotter. Ointments of one percent, of phenol or of one to five 
percent, of menthol are occasionally useful, but on the whole irritate 
the skin more than they relieve it. Lotions, baths and washes when 
employed frequently tend to dry out the skin. In this event, either 
powders or a zinc paste, consisting of from thirty-three to fifty 
percent, of zinc oxide in lanolin, or in equal parts of lanolin and 
vaseline, should be used. Frequently following urticaria, as indeed 
after all itching diseases, the skin may continue to itch after the 
acute process is over. Whether this is a cutaneous neurosis or not 
is not known. When all efforts to alleviate these cases by the use of 
ordinary antipruritics prove fruitless, the Roentgen rays will often 
succeed. 

Schloss's studies in egg urticaria indicated the anaphylactic nature 
of at least this one type. Many investigators have sought to apply 
to urticaria of other origin the principles embraced in this concept, 
with the therapeutic idea as prominently in mind as the diagnostic. 
Proteid extracts in dry form have been prepared from nearly all 
foods, some bacteria, and even such substances as horse dander, 
chicken feathers and the like. With these materials, suitably con- 
trolled percutaneous tests are preformed. If wheals larger than 
the controls develop, or if they are encircled by a hyperemic zone, 
the particular proteid or proteids producing the reaction are 
regarded with suspicion. It does not follow, however, that a pro- 
teid indicating sensitization is actually the cause of an existing 
disease; nor does it follow that proteids producing no reaction are 
not the cause. But it is a matter of experience that the causative 
factors, if the urticaria actually be due to a food, will be among 
those giving positive reactions. To prove this it is necessary to 
feed the patient with the suspected foods. If then, no other food 
having been eaten, an urticarial attack supervenes, this particular 
article of diet may be assumed to be pathogenic. In this manner I 
have found in one patient that buckwheat provoked angioneurotic 
oedema of the eyelids, in another that veal did, in another that 



48 DEKMATOLOGY 

carrots caused recurrent urticaria, in another a like role played by 
pork. After eliminating these foods further attacks ceased. 

It would be impossible to go into the matter in as much detail as 
both its interest and possible practical value merit. But emphasis 
should be laid on these facts. After positive percutaneous tests are 
found, the pathogenic role of the particular substance must be estab- 
lished by ingestion. If this causes renewed attacks the food should 
be removed from the patient's dietary, unless it is so important that 
active immunization would be warranted, an eventuality rarely con- 
ceivable in an adult. 

Prognosis. The prognosis in most cases of urticaria is good. 
There are persistent forms, though, which through their constant 
itching with its resultant loss of rest, wear patients out In indi- 
viduals whose attacks invariably are caused by definite substances, 
the predisposition is the disease and is incurable save by artificial 
immunization. The prognosis as to the individual attacks however 
is good. 

In intimate relation with urticaria are three other diseases, 
angioneurotic edema, urticaria pigmentosa and infantile prurigo 
which links the urticaria group with prurigo. 

ANGIONEUROTIC EDEMA 

Synonyms. Giant Urticaria; Urticaria Edematosa; Wandering Edema; 
Acute Essential Edema ; Quincke's Edema ; Acute Circumscribed Edema. 

Definition. Angioneurotic Edema is an infrequent, acute, recurrent dis- 
ease of the skin or mucous membranes characterized by the sudden appear- 
ance of an edematous swelling varying from the size of a walnut to that 
of a hand. 

Symptoms. The onset of this disease is sudden, at times accompanied 
by moderate fever, vomiting, diarrhoea, nervousness or psychic depression. 
It tends to appear in the early morning hours, and frequently patients who 
have had previous attacks have premonitions of an impending one. The 
lesions are huge wheals including the skin and subcutaneous tissue. They 
are usually solitary, occasionally multiple, and at times return at one 
particular spot. They are white as a rule, but may be red; and they itch, 
burn, or pain and give rise to a sensation of tenseness. Their consistency 
is usually elastic and hard, but not invariably. Their shape is circular, 
oval, or irregular and their favorite sites, in the order of frequency, are the 
face, genitalia, or anywhere on the body surface or in the buccal orifice. At 
times when the epiglottis is involved, breathing is interfered with and 
asphyxiation threatened. 

Course. The duration of an attack is a matter of hours, or even days. 
The disease as a whole, however, lasts for years, the recurrences varying in 
frequency with free intervals of increasing length until they cease entirely. 

Differential Diagnosis. It is almost impossible to confuse this condition 



THE, ERYTHEMAS AND URTICARIA 49 

with any other because of the characteristic onset and appearance of the 
lesion. 

Etiology and Pathogenesis. According to Darier, and his views seem 
reasonable, the etiology of giant urticaria is one with that of ordinary 
urticaria. This is probably correct. It is true, however, that the disease 
is more frequent among women than men, that it is often familial, and 
associated with emotional disturbances, goitre, neuralgia and psychic dis- 
eases, chiefly melancholia. 

Treatment. The treatment, both local and general, parallels that of 
urticaria. When the epiglottis is seriously involved, intubation is 
indicated. 

URTICARIA PIGMENTOSA (FIG. 4) 

Synonyms. Xanthelasmoidea ; Chronic Urticaria leaving Brown 
Spots. 

Definition. Urticaria Pigmentosa is a rare disease usually be- 
ginning within the first year of life characterized by the gradual 
appearance and progressive increase of brown maculo-papular or 
nodular lesions which, upon irritation, become evanescent wheals. 

Symptoms. The disease usually begins before the end of the 
first year with tan spots or wheals which turn brown and gradually 
increase in size and number. The back is most frequently involved, 
chiefly the lumbar region and buttocks (Fig. 4). From these sites 
the lesions may spread to the rest of the body, rarely including the 
neck and face, and still more rarely the buccal mucosa. To find the 
lesions elsewhere than on the back and buttocks is exceptional. At 
times slight itching is present, but there are no constitutional 
symptoms. 

The lesions vary from the size of a lentil to a lima bean, and 
are macular, papular, nodular, or a mixture of the three. They 
are symmetrical as a rule, numerous, although cases with but from 
two to six spots have been reported. They tend to follow the 
cutaneous lines of cleavage and their color shades from a yellowish 
bronze to brown. In typical cases the affected areas suggest the 
striped markings of a tiger (Fig. 4). When irritated, wheals rise 
at the sites of the lesions, or the lesions get redder and larger. This 
is transitory. Dermographism is frequently present, as well as a 
general glandular enlargement. 

Course. The disease is chronic and the pigment persists; but 
the entire process usually ends at, or at the end of adolescence. 

Varieties. There is but one known variety of this disease. 

Differential Diagnosis. There are many cutaneous diseases 
characterized by discolorations, but only two strongly resembling 



50 DERMATOLOGY 

urticaria pigmentosa. These are urticaria with pigmentation and 
xanthoma tuberosum (Fig. 41). Urticaria with pigmentation does 
not begin in infancy and is characterized by the typical picture of 
urticaria, sudden onset, intense itching, constitutional symptoms and 
rapid disappearance of the lesions, except the pigment they leave 
which fades gradually. Urticaria pigmentosa begins gradually in 
infancy, changes slightly if at all, is devoid of constitutional symp- 
toms and the pigment never disappears during childhood. Xan- 
thoma is almost never seen in infancy and the lesions are, for the 
most part, orange yellow. It has a definite microscopic structure, as 
has also urticaria pigmentosa. The latter is characterized by a dense 
infiltration of mast cells distinguishing it from any similar disease. 
This point is mentioned because a microscopic study of the lesions 
may be essential in diagnosis. 

Etiology and Pathogenesis. The etiology is absolutely not un- 
derstood. The disease is obviously due to a congenital disturbance, 
either anatomic or metabolic. J^eisser considers it a nevus; Little 
a congenital tendency to overproduce mast cells; Knowles thinks 
it is due to an unknown toxin affecting a congenitally abnormal 
skin, the most reasonable view of the three. 

Treatment. There is no known effective treatment. 

Prognosis. The prognosis as to life is good. The pigmenta- 
tion usually disappears in time. 

INFANTILE PETJEIGO 

Synonyms. Strophulus Infantum; Urticaria Chronica Infan- 
tum; Varicella Prurigo; Lichen Urticatus; Prurigo Temporanea. 

Definition. This is a not very well defined disease of childhood, 
the characteristic features of which are the presence of wheals, papu- 
lar and vesiculo-papular lesions accompanied by severe itching. 

Symptoms. The disease begins early in life and its onset is 
gradual. At first wheals appear, upon which develop small shotty, 
brownish-red or red umbilicated papules, some of which are sur- 
mounted by vesicles. The sites most intensely involved are the 
extensor surfaces of the extremities, flanks and lower abdomen, 
but no area of the body surface is necessarily immune. Successive 
groups of lesions develop so that all stages may co-exist, creating a 
varied picture. Scratching causes consecutive lesions. At the sum- 
mits of the vesicles and papules punctate brown crusts form. Dif- 
fuse, long excoriations exist by the side of these, and in places the 
skin becomes thickened. Dermographism is present. To the touch 



THE ERYTHEMAS AND URTICARIA 51 

the skin is roughened and it feels like a grater. Rarely, secondary 
infections add impetiginous lesions with their types of crusts, to an 
already diversified picture. Constitutional symptoms, save possible 
constipation, are entirely wanting. Occasionally, a peculiar ashy 
pallor is seen. 

Course. The disease is chronic, lasting throughout childhood, 
and disappearing between the eighth and tenth years. 

Differential Diagnosis. Two conditions simulate this one — 
scabies and prurigo. The former favors the skin folds, flexors and 
interdigital spaces, etc. (See Scabies.) A demonstration of the 
acarus clinches the diagnosis. Prurigo begins in early life and 
persists throughout adult years. Since many cases of prurigo begin 
as lichen urticatus there are no positive criteria for differentiation 
between the two excepting the course of the disease. 

Etiology. The etiology suggests that of urticaria as far as the 
proteid origin of that disease is concerned. 

Treatment. The treatment corresponds in general with that of 
urticaria, but a few special points must be borne in mind. Inter- 
nally arsenic and iron are often of great avail. Locally, tar and 
sulphur salves and pastes, in addition to the medicaments suggested 
in the treatment of urticaria, are useful. 

5 01. Rusci : 4, to 6, or Sulphur ppt. 5, 

Zinc Oxid : 20, 
Petrol. Flavi: q.s. ad 50, 
Sig. Apply twice a day, once after bathing. 
^ 01. Rusci : 1, 

Alcohol: q.s. ad 50, 
Sig. Paint body once a day after bathing. 

Prognosis. The general health is not affected in this disease. 
The attacks are amenable to treatment to the extent that their dis- 
agreeable symptoms are controllable, and that frequently the erup- 
tion may be caused to disappear. The disease as a whole goes 
spontaneously at the end of childhood. 

PRURIGO' (fig. 5) 

Synonyms. Prurigo of Hebra. 

Definition. Prurigo is an infrequent, chronic disease beginning 
in infancy as chronic urticaria, lasting either through adolescence or 
throughout life, and characterized by the presence of wheals, papules 
and consecutive lesions due to scratching and pruritis. It is often 
accompanied by profound constitutional disturbances. 



52 DEKMATOLOGY 

Symptoms. The disease begins in infancy by the gradual in- 
crease, in successive crops, of wheals, and papules developing upon 
wheals, and accompanied by intense itching which is worse at night. 
As the result of scratching secondary lesions develop. The papules 
vary in size from that of a millet seed to a pea (Fig. 3). They are 
red, brown, or yellowish, hard, shotty and convex or obtuse, single or 
grouped, and situated primarily on the extensor aspects of the limbs 
(Fig. 5), next on the trunk, and finally anywhere else on the body, 
sometimes including the face. Scratching causes destruction of the 
summits of the papules, at which sites brown blood crusts develop. 
Other types of excoriations, irregular in length and distribution, are 
found. The skin becomes lichenified or " eczematized " in spots, and 
thus areas of thickening, vesiculation, redness and scaling are found. 
In severe forms the entire integument becomes leathery. Secondary 
infection causes impetiginous lesions and ulcerations which leave 
depressed pigmented scars, adding marked pitting to a leathery skin 
which may become diffusely bronzed. Thus a patient, in the severer 
forms of the disease, is enveloped in a thick, brown integument 
studded over with papules, ulcers and pigmented scars. The skin 
feels inelastic when pinched, and sometimes it is impossible to fold 
it sufficiently to raise it from the lower tissues. The glands, par- 
ticularly the inguinal groups, become enormously enlarged, and 
visible as well as palpable. 

Course. The general health suffers, sometimes seriously, partly 
from the underlying cause of the disease, partly from the constant 
anguish and disturbed rest of the sufferer. The milder forms dis- 
appear at the end of adolescence; the severer forms persist to the 
termination of a life usually shortened by intercurrent infection. 

Varieties. There are two types of prurigo ; the mild, or prurigo 
simplex or mitis, and the severe, or prurigo ferox, agria or gravis. 
The former is the type which disappears at the end of adolescence ; 
the latter, the type which terminates in death. It is believed that 
these two types are distinct from the onset, prurigo ferox beginning 
with much intenser symptoms which grow more and more severe. 

Differential Diagnosis. The diagnosis of prurigo rests upon 
the clinical history and appearance of the case. The disease begins 
in infancy, growing progressively worse. It is characterized by 
the site and appearance of the lesions, and the constitutional symp- 
toms. Actually, nothing else suggests prurigo, but at times scabies 
(Fig. 43) and papular dermatitis may be confused with it upon first 
glance. Scabies is to be differentiated on the history, the milder 



THE ERYTHEMAS AND URTICARIA 53 

course of the disease, and the presence of the mites. Papular derma- 
titis usually begins later in life, is less severe, and the characteristic 
vesicles and scaling are present. Only in eczematized prurigo will 
confusion arise, and the history of the case will eliminate this. Ob- 
viously, prurigo must be differentiated from infantile prurigo, an im- 
possibility until the end of childhood. 

Etiology and Pathogenesis. The disease is due to disturbed 
metabolism causing a chronic intoxication, possibly anaphylactic, 
as shown by Hans Schwartz. The source of the poison is alimen- 
tary. Disturbed nitrogen metabolism and the excessive ingestion 
of proteids are associated conditions. 

The disease is not common and is more frequent in Austria than 
elsewhere. Heredity, poverty, tuberculosis, anemia, filth and the neurotic 
habitus have all been held etiologically responsible, the last chiefly by the 
French school; and in the nervous group have been included the reflex 
phenomena of dentition, puberty and the climacteric. The interrelation 
between anaphylaxis on the one hand, and neuroses causing vague insta- 
bility, tryptic indigestion, excessive proteid intake and disturbed nitrogen 
metabolism, on the other, are facts clearly indicated by Schwartz. The 
general factors of heredity and lack of hygiene would be contributory. The 
comprehensive list of causes hangs together consistently when properly 
reviewed. 

Treatment. The treatment is prophylactic, eliminative, tonic 
and local. The prophylactic treatment consists of cutting down on 
proteid foods. Eliminative treatment demands free catharsis, intes- 
tinal irrigation, diuresis and hot packs. Tonic treatment consists 
of the use of arsenic either in the form of Fowler's solution, injec- 
tions or Asiatic pills, and calcium lactate in three gramme doses 
before breakfast. 

Intestinal antiseptics are of little benefit. Obviously, when itching is 
intense sedatives should be employed. 

Local treatment has two objects; to control the itching and to 
cause the lesions to disappear. The itching may be controlled along 
the lines laid down in the treatment of urticaria. This, as well 
as the second object, may be attained by the use of revulsives and 
keratolyses, followed by sedative and keratoplasty medicants. Re- 
vulsives cause an inflammation of the skin and keratolyses a degen- 
eration of the epidermis. In consequence the skin peals and the 
redundant epidermis and the infiltration are removed. To soothe 
the skin, after this, sedatives are employed, and to stimulate new 
formation of epidermis, keratoplasties. In prurigo, the best revul- 



54 DERMATOLOGY 

sives and keratolyses are tar, sulphur, salicylic acid and resorcin in 
high concentration. The best way of treating the patients is to 
paint the affected surfaces with ten percent. Oleum Rusci in alcohol, 
and immerse them in a hot bath for an hour. After drying, a mild 
ointment (ten percent, zinc oxide in lanolin or vaseline) is gently 
applied. Wilkinson's ointment (01. Rusci, Flor. Sulph. aa 10,0 
Sap virid., Petrolatum aa 20,0) may be substituted for the tar solu- 
tion; or two to five percent. B. Xaphthol solutions or salves are valu- 
able. After the application of these substances, the patient should 
be loosely wrapped up in single layers of gauze. In the course of 
several days the skin will become inflamed. Then sedative appli- 
cations are to be used. One of the best is Lassar's Paste. It is to 
be applied gently to the entire affected surface twice a day. In addi- 
tion, wet dressings of two percent, aqueous resorcin solution for 
half an hour, three times a day, to restore the epidermis, followed 
by calamine lotions, with or without one percent, of phenol, are 
indicated. Should the skin be impetiginous ammoniated mercury 
ointment is to be used until the special need for it disappears. Then 
the treatment with tars and sulphur is to be begun. 

Prognosis. In prurigo mitis the prognosis is good, since the 
disease vanishes at the end of adolescence. In the other form, 
recovery never takes place and death usually supervenes. 

PRURIGO XODTJLABIS 

Synonyms. Multiple tumors of the skin accompanied by intense pruritis ; 
Urticaria Perstans Verrucosa; Lichen Obtusus Corneus. 

Definition. Prurigo Nodularis is an extremely rare, itching, nodular 
eruption of the backs of the hands, extremities and trunk. 

Symptoms. The disease is gradual in onset, intensely pruritic, begins 
on the backs of the hands, involves the extremities and trunk, and is found 
chiefly among women. The lesions are papules from the first, or nodules, 
rising upon papules or vesicles, develop. At first they are smooth and white 
or pink, but grow rough and, gradually, warty, with age. Scratching fissures 
or furrows the surfaces. The lesions often coalesce. 

Course. The course is chronic extending over prolonged periods of years. 

Etiology and Pathogenesis. The etiology is not understood. 

Treatment. Extirpation of the lesions and Roentgen therapy have been 
used without avail. 

Prognosis. The disease is incurable. 




Fig. 1. ERYTHEMA EXUDATIVUM MULTIFORME 

In this disease the back of the hands, wrists, neck, vicinity of 
the ascending ramus of the jaw, and finally any part of the body 
may be involved. The lesions are pink, red, or even purple, 
slightly elevated, and sharply circumscribed edematous discs, at 
times, by coalescence, forming festooned patches. Sometimes 
bullae arise in the centres; sometimes concentric rings of red and 
purple form, giving the respective pictures of erythema bullosum 
and erythema or herpes iris. 




ERYTHEMA NODOSUM 



The shins seem covered with bruises of all sizes. The localization is 
characteristic of the disease. In erythema induratum (Bazin's disease) 
the lesions are rather on the calf, and many break down. Necrosis is rare 
in erythema nodosum. At times there is scaling, as the left shin shows. 
In syphilitic erythema nodosum fewer lesions, occasional necrosis and 
periosteal thickening are present. Erythema nodosum is often associ- 
ated with erythema multiforme. 







H3 o 




<D .r-l 




■+-> r& 


*T^ 




, 


bo t» 


*^ 


2 ,rH 






-1-; 
Q 


.s."g 




.s s 


~ i 


r" 


*H r ~ ' 


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^ r 

9 












URTICARIA PIGMENTOf 



A better designation is xanthelasmoidea because of the vague similarity 
to Xanthoma. The lesions are flat buff or brown papules which, under 
friction, become slightly elevated and resemble wheals. The lesions group 
themselves roughly into stripes, a configuration here seen above and on the 
buttocks. There is a suggestion of spotting as seen in leopards. The dis- 
ease occurs only in the young, disappearing, as a rule, during adolescence. 




Fig. 5. PRURIGO 

Small excoriated papules, mainly on the extensor surfaces of the limbs, and 
all over the torso, characterize this condition. The face is also involved, and 
the skin becomes thickened, or lichenified. In scabies the face is free, and 
the lesions favor the body folds and flexor surfaces. At times, prurigo-like 
lesions appear in leucemia, and thus it is well to exclude this condition in all 
cases of prurigo in adults. 



CHAPTEE VII 

DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 
DKUG EEUPTIOKS 

Because of the great variety of cutaneous reactions medicaments 
and chemicals are capable of producing, only those will be here 
described which have a frequent bearing upon ordinary dermato- 
logical practice. These dermatoses are closely allied to those of 
occupational origin caused by chemicals. Whether the pathogenic 
agent is ingested or locally applied, the brunt of the attack is borne 
by the cutaneous vessels. Dermatoses due to ingested drugs or 
chemicals tend to be disseminated and symmetrical, while those due 
to external irritants tend to be limited to the area exposed. This 
rule, however, is not inflexible. Arsenic when taken internally some- 
times causes herpes of the zoster type; quinine employed locally, as 
it often is in hair washes, or belladonna locally applied in plasters, 
may both provoke generalized rashes; chemicals occasionally are the 
starting point of eruptions which extend far beyond their point of 
application. (See Chapter on Dermatitis and Eczema.) 

The pathological changes underlying these diseases are congestion, 
exudation and necrosis. The primary objective expression of con- 
gestion is redness ; of exudation, edema, and the formation of vesicles 
or bullae containing serum or blood, or both ; and finally, of necrosis, 
or ulceration. The secondary objective expressions of these phenom- 
ena are scaling, pustulation, weeping, crusting and scarring. The 
symptoms consist of itching, tingling, burning or pain, or any 
subjective sensations whatever. In iodide and bromide poisoning, 
however, pustules and pustular granulomas form, not necessarily due 
to a secondary infection. Arsenic may cause palmar and plantar 
hyperkeratosis. (Chapter XV.) 

The following table based upon Crocker's, and abridged in some respects, 
while amplified in others, indicates in clinical groups the variety of lesions 
which therapeutic agents administered internally may provoke. 

Erythema. Arsenic, antipyrin, belladonna, boric acid, bromides, can- 
tharides, capsicum, chlorate of potash, chloral, copaiba, Dichloramin T 
and Carell-Daikin solution, digitalis, iodides, iodoform, mercury, morphine 

55 



56 DERMATOLOGY 

and its derivatives, pyramidon, phenacetin, phenophthalein, quinine, salicy- 
lates, sera, strychnine, sulphonal, veronal. 

Vesicles. Antipyrin, arsenic, bromides, cantharides, cannabis indica, 
capsicum, chloral, copaiba, Dichloramin T and Carell-Daikin solution, 
ergot, iodides, morphine, quinine, salicylates, sera, sulphonal. 

Bullae. Antipyrin, arsenic, cannabis indica, copaiba, chloral, iodides, 
mercury, opium and its derivatives, quinine, salicylates, sera. 

Wheals. Antipyrin, arsenic, bromides, copaiba, iodides, iodoform, qui- 
nine, salicylates, sera. 

Pustules. Arsenic, bromides, chloral, iodides, mercury, salicylates. 

Purpura. Antipyrin, arsenic, chloral, ergot, iodides, iodoform, mercury, 
quinine, salicylates, sulphonal. 

Erythroderma. Arsenic, arsphenamin, mercury. 

"Eczema." Arsenic, iodoform, mercury. 

Necrosis. Arsenic, ergot, iodides. 

Hyperkeratoses. Arsenic. 

Granulomas. Bromides, iodides. 

Herpes. Arsenic, arsphenamin. 

Cyanosis. Antipyrin, acetanilid. 

Pigmentation. Arsenic, silver, bismuth, lead. 

Mucous Lesions. Arsenic, bismuth, lead. 

Angioneuroses. Aspirin. 

Of this extensive list it is important to bear in mind a few 
substances and the lesions they may provoke. It must also be 
remembered that in average doses they are toxic only to the sus- 
ceptible, in other words, to but few individuals. The iodides are the 
one exception to this rule, for the majority of people are found in- 
tolerant to them in one way or another. These drugs may be 
classified according to their source, and with their important repre- 
sentatives as follows : 

I. Medicaments derived from Animal Sources : 
Sera, small pox virus. 
II. Medicaments derived from Vegetable Sources : 

Belladonna, quinine, copaiba, digitalis, opium and its 
derivatives. 
III. Medicaments derived from Mineral Sources: 

1. Metallic elements and their compounds; arsenic, bis- 
muth, lead and silver. 

2. Non-metallic elements and their compounds; iodides, 
iodoform and bromides. 

IV. Synthetic Medicaments: 

Antipyrin, pyramidon, chloral, sulphonal, veronal, sali- 
cylates. 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 57 

SERUM SICKNESS 

Definition. This disease is characterized by a polymorphous 
eruption associated with a systemic reaction following the injection 
of alien serum. 

Symptoms. The symptoms are cutaneous and general. The 
cutaneous manifestations consist of the appearance of an eruption 
which, according to von Pirquet and Schick, has the following attri- 
butes. It first appears at the site of the injection, spreads symmet- 
rically, the urticarial forms itch, and the exudative and morbilli- 
form varieties favor the extensor aspects of the limbs. Hartung 
mentions four varieties of eruption, the urticarial, scarlatiniform, 
morbilliform and polymorphous exudative. As a matter of fact 
no such distinctions can arbitrarily be made since the enumerated 
types may coexist and since there are intermediary forms. Ormsby 
adds to these the rare vesiculo-bullous rashes. 

The general manifestations are numerous. Regional glandular 
swellings take place, subject to the site of injection, and their onset 
and disappearance precede the arrival and departure of the rash. 
Edema, usually without albuminuria, is common. It is found on 
the face, eyelids, penis, scrotum and feet, suggests angioneurotic 
edema, and has no renal disturbance as a basis. A leukopenia with 
high relative lymphocytosis is common. Arthralgias, malaise and 
prostration are all frequent concomitants of the malady and fever is 
a constant feature. The temperature rises to 101° or even to 105° 
in the afternoon; it is remittent, disappears by lysis and recrudes- 
cences are common. With the height of the fever the glandular 
enlargement reaches its maximum. 

Course. The onset of the attack, preceded by glandular swelling, 
usually occurs in from one to two weeks after the injection, but 
may come much earlier or later. At the same time malaise and 
slight fever appear. The rash begins near the puncture and then, be- 
coming disseminated, assumes the character mentioned above. As it 
spreads the glands increase in size, while the fever rises more and 
more. The attack is likely to end within a few days, but may last 
four or five weeks. Recurrences are not uncommon. The types 
resembling scarlet and measles desquamate. Re-injection, if at too 
short an interval, often causes severer attacks. 

Diagnosis. The main diagnostic factor is the history of the in- 
jection. The next in importance is its beginning near the puncture 
wound. Since measles and scarlatina often develop in children with 



58 DERMATOLOGY 

diphtheria, and since serum therapy is almost entirely restricted to 
diphtheritics, or those exposed to this disease, scarlatina and measles 
often must be ruled out. This is usually easy. In scarlatina the 
onset with vomiting, the angina, strawberry tongue and enanthem 
serve as guides in diagnosis. In measles, the usual coryza, con- 
junctivitis, bronchitis, and, in the prodromal stage, Koplik's spots 
are sufficiently distinctive. The urticarial and exudative types of 
serum disease can be distinguished from hives and the toxic and 
multiform exudative erythemas, solely by the history. 

Etiology and Pathogenesis. The cause of the disease is the 
foreign proteid contained in the serum and not the antitoxin as 
was once supposed. The patient is susceptible to the substance, and 
as has been shown by von Pirquet and Schick, may become hyper- 
susceptible when sensitized by the first injection and exposed upon 
re-injection at too short an interval. Re-injection may cause the 
appearance of the attack within a few hours after administration. 
Thus, the question of etiology becomes one with that of anaphylaxis, 
along the lines indicated in the discussion of urticaria and multi- 
form erythema. 

Treatment. This is largely prophylactic. Yon Pirquet and 
Schick have demonstrated that small doses of serum containing a 
high concentration of antitoxic units tends to lessen the incidence 
of the phenomenon. In addition too freshly prepared antitoxins 
should be avoided. If re-injection becomes necessary, as in re- 
current attacks of diphtheria, antitoxin should be employed pre- 
pared from an animal x other than the serum of which was used in 
the first treatment. For the rest, the local and general treatment 
outlined in the chapter on urticaria should be followed. 

Prognosis. The disease is never fatal, nor is it followed by any 
permanent disability. Because of its severity while it lasts, how- 
ever, it should be guarded against. 

Small pox virus. This is a substance capable of producing two 
noteworthy types of cutaneous response, — vaccinia and a bullous 
dermatitis. 

Vaccinia is either localized or generalized. The localized vaccinia 
is the pustule developing at the site of a successful inoculation, and 
its characteristics are sufficiently well known to require no space 
here. Generalized vaccinia is due to a dissemination of the virus 
from the point of application over the rest of the body, — an auto- 

i Horses are usually utilized. For re-injection sheep antitoxin may be used in 
patients sensitized to horse serum. 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 59 

inoculation. The transfer is accomplished mechanically and the 
lesions develop in from four to ten days after the original vaccina- 
tion. Each lesion undergoes the course of a vaccine pustule, begin- 
ning as a papule, becoming a vesicle, then an ulcerated pustule, and 
finally, crusting and healing with a superficial scar. They appear 
in successive crops accompanied by systemic symptoms of an in- 
tensity directly proportionate to the number and severity of the 
lesions. At times the lesions are hemorrhagic. 

Bullous Dermatitis following Vaccination. This condition is un- 
common, but merits attention. It occurs in two varieties; a mild 
form resembling dermatitis, herpetiformis, and a severe form, fre- 
quently fatal, resembling acute pemphigus. Bowen (Journal of 
Cutaneous Diseases, 1901) reported six cases of the mild type and 
Corlett later added another. How, in the same Journal, reported 
cases of the severe type and Mook has reported eight cases, three of 
which terminated in death. 

In both groups systemic reactions, fever, prostration, albuminuria, 
are present, varying in intensity. The incubation period is from 
four days to as many months, and the disease develops irrespective 
of whether the vaccination was successful or not. It is prone to 
recur and its course is of variable length up to seven months. It 
bears no resemblance to vaccinia. Mook was unable in a series of 
well conceived studies to isolate the causative agent. A personal 
predisposition must exist since only a small proportion of the patients 
vaccinated with a given virus were affected. 

Belladonna. Belladonna causes an eruption resembling scar- 
latina. Even the small quantities employed in diseases of the eye 
may produce eruptions in the susceptible. The rash consists of a 
diffuse erythema, often intensified by punctate macules of a deeper 
red; or it is composed of a general confluence of such macules. It 
fades without desquamation after the drug is no longer administered, 
and is usually accompanied by dilatation of the pupils and dryness 
of the pharynx. The history of the use of the drug, the midriasis 
and suppression of saliva, the absence of fever, angina and vomiting 
at the onset, all serve to distinguish it from scarlatina, with the 
earlier stages of which it may be confused. 

Quinine provokes erythemas, vesicles, bullae and wheals. Even 
small quantities of this substance are sufficient to excite such 
cutaneous reactions in the oversensitive; nor need the drug be in- 
ternally administered. In a manner analogous to egg albumin urti- 
caria the external application of the drug, in scalp lotions for in- 



60 DEKMATOLOGY 

stance, may produce an attack. The commonest manifestations are 
the erythematous and urticarial, resembling the toxic and exudative 
multiform erythemas, or ordinary hives. The latter itch. Vesicles 
and bullae may develop upon the simpler lesions, but are rare. 
Polymorphism is often present. Ringing of the ears is frequently 
associated with the rash, and occasionally there is vomiting. 

Copaiba also causes lesions resembling those produced by quinine. 
The only important variety, however, is an itching erythema closely 
simulating the macular syphiloderm, or roseola. Since this drug is 
used in the treatment of gonorrhoea, and since the latter is at times 
associated with syphilis, the diagnosis between copaiba rash and the 
roseola may be a difficult one to establish. The history of taking a 
drug, and the pruritus, coupled with the absence of corroborative evi- 
dence of syphilis, constitute a reasonably certain basis of differentia- 
tion. 

Digitalis may rarely cause an erythema resembling the toxic 
variety. Because it is indispensable in the treatment of cardiac dis- 
ease in which toxic erythemas often arise, particularly when the 
heart lesions are due to rheumatism or sepsis, it is necessary to de- 
termine whether the drug or other agents are at fault. Dilatation 
and overactivity of the heart, as well as gastric irritability, may 
accompany digitalis eruption. The differential diagnosis depends to 
a great extent upon persistence of the rash after interrupting the 
use of the drug. In this event other forms of toxic eruption are to 
be considered. (See Chapter VI.) 

Opium and its derivatives may cause erythemas, vesicles, bullae, 
pruritus, diaphoresis, pustules, ulcers and scars. The first three 
conditions are rare except as secondary to the fourth. The last three 
have a peculiar significance. The most important by far is the 
pruritus which is severest about the nostrils, but may be general- 
ized and not associated with visible lesions. In the event of free 
diaphoresis sudaminal vesicles may develop (see miliaria crystal- 
lina), and these heal with desquamation. With diaphoresis, too, 
erythemas and wheals are at times associated. The pustules, ulcer- 
ation and scarring are all due to one and the same cause, not to the 
drug, but to its hypodermatic injection under careless asepsis. This 
is observed only in addicts who inject themselves, and a distinguish- 
ing feature of this cutaneous phenomenon is the presence of the 
lesions only on parts of the body accessible to the hand employed in 
the injection. Thus, the right upper extremity and other parts 
without the range of the hand of a right-handed individual will be 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 61 

free. The pustules resemble small furuncles, the ulcers ecthyma, 
and the scars those of variola. The face never is scarred. The dif- 
ferentiation from small pox cicatrices can be made only by the 
curious distribution. Concomitant features of opium eruptions are 
contracted pupils, moist skin and mental torpor or somnolence. 

Arsenic, Fowler's solution, Asiatic pills, arsphenamin and other 
arsenicals, in the predisposed, all cause a great variety of cutaneous 
disturbances, namely, erythemas, vesicles, bullae, wheals, pustules, 
purpura, dermatitis, necrosis, hyperkeratosis, herpes, pigmentation 
and mucous congestion. Of these, the erythemas, dermatitis, hyper- 
keratosis, herpes, pigmentation and the arsphenamin dermatoses 
are important. The rest are rare. Arsenical erythema is scarla- 
tinoid in character. Dermatitis of arsenical origin is not frequent, 
but must be recognized. Clinically, it has the common features of 
this disease. (See Chapter IX.) Harding reported cases of this 
nature in two families, caused by the use of insect powder. Hyper- 
keratosis excited by this metal is usually limited to the palms and 
soles. Rare forms of hyperkeratosis have been reported. The 
palmar and plantar lesions have a curious velvety feel, and are fawn 
colored. As Udo Wile pointed out epithelioma may develop upon 
this basis, particularly in psoriatics, a confirmation of the experiences 
of White, Hutchinson, Hartzell, Darier, Schamberg and others cited 
in Wile's article. Herpes of the simple variety, about the nose and 
lips, is not infrequent, and occasionally a form suggesting zoster, 
particularly in the region supplied by the supra-orbital nerve, is seen. 
Lustgarten believed that this form occurred only in anemic or under- 
nourished individuals. The pigmentation strongly resembles that 
of Addison's disease. Another type, however, is observed in psori- 
asis and lichen planus. In these diseases the lesions, after fading, 
tend to leave pigmented spots and the discoloration is supposed to be 
more intense after arsenic therapy. 

Arsphenamiis" sometimes causes either simple herpes, or a variety 
resembling zoster. Immediately after the intravenous injection of 
arsphenamin a fugaceous erythema sometimes arises. It starts about 
the face and neck, rapidly involves the trunk, arms and thighs, and 
fades within half an hour or so. It is either morbilliform or scar- 
latinoid, does not itch, and is sometimes associated with hyperemia 
of the conjunctiva and buccal mucosa, dyspnoea and epigastric pain. 
At times it is followed by fever and diarrhoea. This syndrome is 
most frequently observed after the third or fourth injection, and 
strongly simulates an acute anaphylactic attack, as pointed out by 



62 DERMATOLOGY 

Homer Swift, even though the toxic agent is not protein. Another 
type of skin disturbance is one that arises within a week after the 
administration of salvarsan. This is extremely rare and resembles 
the scarlatinoid erythrodermas. (See Chapters VI and XII.) It 
begins either as the form just described, or starts after from three to 
seven days with a universal, highly itching erythema, strongly re- 
sembling scarlet without throat symptoms, and is accompanied by a 
high remittent fever, prostration, vomiting, diarrhoea, and at times 
suppression of urine. When renal function is again established al- 
buminuria and hyalo-granular casts are observed. Although death 
is unusual in these instances, the patient is severely ill. The course 
of the disease lasts from three weeks to three months, the skin re- 
turning to normal after a prolonged period of itching and scaling. 
Whereas the first type of adverse reaction appears to be due to 
sensitization, developing as it does after three or four injections, 
the second variety often comes after the first injection and would 
thus appear to be due to a fundamental intolerance to arsenic with- 
out reference either to its cumulative effect, or to sensitization. 

Mercury. When applied locally mercury is capable of producing 
dermatitis through its irritant action, but when injected it usually 
has no effect upon the skin, although Jarisch has reported 
erythemas, eczemas and purpuras. Considering the amount of mer- 
cury that is used in medicine and the rarity of such eruptions fol- 
lowing its use, it is difficult to hold mercury responsible for them. 
In the mucous membranes of the buccal orifice, on the other hand, it 
produces changes, and since stomatology is included in dermatology, 
these must be understood. The mucosa becomes red, edematous, 
painful, the gums in particular being affected, and small gray ulcers 
on an inflamed base develop, some of which resemble syphilitic 
mucous patches, and others aphthae. Because of the use of mercury 
in syphilis, the ulcers caused by the former must be differentiated 
from those due to the latter. (See Section on Syphilis, Mucous 
Patches.) Diarrhoea sometimes, ptyalism always, is associated with 
these phenomena, the ptyalism usually being the first sign of mer- 
cury poisoning. Formerly loss of teeth and necrosis of the alveolar 
process were frequent consequences of the unrestricted use of mer- 
cury in the treatment of syphilis, for in those days it was thought 
that the therapeutic value of the drug was insufficient unless the pa- 
tient had mercurialism. 

Bismuth. Bismuth as the cause of changes within the province 
of the dermatologist has, until recently, received no recognition. 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 63 

Baehr and Mayer, in connection with the use of Beck's paste in the 
treatment of obstinate bone sinuses, described buccal ulcers in three 
patients, chiefly in the lower gum and tongue, and a pigmentation on 
the tongue and gums. The pigmentation was in the form of a fine 
line made up of blue-black points, just at the edge of the gums, the 
tip of the tongue and, in one instance, on the inferior laryngeal sur- 
face following the ranine veins. The tongue was swollen and ex- 
tremely painful. Two cases recovered from the general symptoms 
of bismuth poisoning, but the pigmentation persisted. The third 
patient died. She not only had the mouth manifestations enumer- 
ated, but a morbilliform universal rash which lasted for two days. 

Lead. This causes no cutaneous manifestations, but in the mouth 
is seen the " lead line," a violet streak of pigmentation on the lower 
gum, a short distance below the insertion of the teeth. 

Silver used protractedly by patients for urethritis, cystitis, or in 
diseases of the nasopharynx and eye, causes a peculiar ghastly, ivory- 
blue or slate colored pigmentation. This is intensest on the face 
down to the shoulder girdle, and usually paler elsewhere. Silver 
pigmentation is known as argyria. 

Iodides (Fig. 6) cause erythema, vesicles, bullae (Fig. 6), wheals, 
pustules, necrosis, granulomata and purpura. No other single drug, 
as already mentioned, causes cutaneous reactions in so large a pro- 
portion of those to whom it is administered. The erythemas are of 
toxic, multiform erythematous, morbilliform and scarlatinoid vari- 
eties. Frequently these are admixed with papules, or papules arise 
independently. They are hard and shotty, tend to appear on the 
face, upper extremities and trunk, and are prone to suppurate, giving 
rise to pustules resembling acne and furuncles. Ecthymatous and 
impetiginous lesions too are found, particularly in connection with 
the bullous and urticarial iododermata. Necroses of the skin may &&• 
velop in connection with these forms, and all such processes heal with 
scarring. One of the nodular forms of iododerma occurring on the 
extremities simulates erythema nodosum. Jarisch mentions a pem- 
phigoid form frequently fatal, and Hallopean has reported a similar 
result in a case of this type. Purpuras, too, are not uncommon. 
The most important varieties of iododerma, however, are the papular 
and pustular. The papular form may cause confusion with the 
papular syphiloderm (Fig. 85) ; the pustular with acne, varicella and 
impetigo. The pustules of iodide acne arise independent of come- 
dones, but this distinction is of no practical value in seborrhoeic pa- 
tients who may be suffering with both acne vulgaris and iodide acne. 



64 DEEMATOLOGY 

Varicella may be simulated to a nicety because of the admixture of 
papules with the pustulo-vesicular lesions which are frequently urn- 
bilicated. The iodide impetigo is more indurated than the ordinary 
typo. 

The history of drug ingestion and iodinuria confirms the diagnosis 
which can never be made solely on clinical grounds. The onset of 
the eruption may take place during the time the drug is being taken, 
or even shortly after it is stopped, and the cause may depend on 
renal insufficiency, for ordinarily the urinary excretion of iodides is 
rapid. The treatment consists of stopping the drug, whereupon the 
eruption gradually disappears. Arsenic is supposed to hasten the 
healing. 

Iodoform causes erythematous eruptions of various types some- 
times associated with severe systemic symptoms simulating the ty- 
phoid variety of uremia. 

The Bromides (Figs. 6 and 7) produce a series of eruptions paral- 
leling those caused by the iodides and in addition two other sorts, both 
granulomatous, one of which is condylomaform, the other tuberous. 
The former tends to occur in infants, but is also found in later life. 
Its favorite site is on the cheek and neck near the angle of the jaw. 
It consists of one or more lesions about the size of a quarter, elevated 
like a plateau, or in the form of a walnut, resting on an indurated 
inflammatory base, and it is composed of numerous minute confluent 
pustules, forming a picture which simulates the cribriform aspect of 
a carbuncle. The tuberous form, known as the bromoderma tuber- 
osum, is found chiefly in adults, most frequently on the shins and 
calves (Figs. 7 and 8), but also on the forearms, and finally, any- 
where else on the body. It is either vegetating in appearance and 
bluish brown to purplish in color, or ulcerous with a vegetating mar- 
gin, or nodular with central necrosis. It closely resembles erythema 
induratum, gumma, sporotrichosis or blastomycosis (see respective 
chapters), from which it must be differentiated. Both of these forms 
are often associated with other bromodermata such as the acne, the 
pustular, vesicular, ete. Infants often get the disease through the 
maternal milk. Epileptics and subjects of hysteria are also often 
afflicted. In short, the disease is seen in patients who for one reason 
or another take the drug over long periods. The treatment is pre- 
cisely like that for iodide eruptions. 

Antipyrin produces erythemas, vesicles, bullae, wheals, and petichiae and 
a rare gummatous lesion of the tongue. Pyramidon produces an erythema. 
Chloral causes lesions exactly like those of antipyrin, as do also Sulphonal 



DKITG ERUPTIONS, EXANTHEMATA AND PURPURAS 65 

and the Salicylates, while Aspirin gives rise to angioneuroses. Veronal 
may cause the numerous varieties of skin reactions observed in antipyrin 
intolerance, as well as erosions about the mouth and anus, described by 
Pollitzer. Thus it will be seen that this group of drugs excites cutaneous 
reactions of the erythemato-urticarial and polymorphous types, with their 
pathological sequellae of vesicle and bulla formation. It may be added that 
innumerable other synthetic substances have similar power. One further 
form of antipyrin rash deserves mention. This is characterized by the ap- 
pearance of circular violaceous macules, about the size of a quarter, which 
appear on the trunk, leave pigmentation when they fade, and tend to recur, 
whenever the drug is resumed, at the same sites. Phenophthalein, em- 
ployed as a cathartic, causes lesions resembling erythema perstans. 

The cutaneous reactions caused by drugs and chemicals applied 
externally will be dealt with in the chapter on dermatitis. They are 
entirely due to the local influence of irritants and these may either 
cause destruction of tissue as in the case of strong acids and alkalies, 
or a catarrhal reaction in the predisposed, as in the case of substances 
which are ordinarily not harmful. 

THE EXANTHEMATA 

The exanthemata are acute infectious diseases of which cutaneous 
manifestations are an important clinical feature. They may be 
divided into two groups in the first of which the skin and systemic 
reactions share equally in prominence; in the second of which the 
eruption is transitory, subsidiary, but characteristic. The first of 
these two groups may be subdivided into two classes : erythematous 
and vesiculo-bullous. The erythematous are measles, German 
measles, scarlatina and Duke's disease ; the vesiculo-bullous are small- 
pox, varioloid, vaccinia and chicken pox. The second group includes 
typhoid fever, typhus, Eocky Mountain spotted fever, cerebrospinal 
meningitis and sepsis. Many of these diseases have an enanthem; 
that is, mucous lesions of definite character best seen in the buccal 
orifice. At this point it is well to remember that although whooping 
cough and mumps produce no enanthem they are often accompanied 
by mouth, lesions. It will be impossible to describe these diseases in 
such detail as would be required in works on internal medicine or 
pediatrics, so that only those features will be referred to which are 
of meaning to the dermatologist. Their therapy will not be dis- 
cussed » as dermatologists are rarely required to treat them. 

MEASLES 

Synonyms. Morbilli, Rubeola; German, Maseru; French, 
Rougeole. 



66 DEKMATOLOGY 

Definition. Measles is an acute infectious disease characterized 
by systemic symptoms, nasopharyngeal catarrh and a characteristic 
exanthem. 

Symptoms. Measles begins gradually with malaise, a catarrh of 
the nose, throat and larynx, bronchitis and conjunctivitis. Thus, 
the eyes water, the patient resents light, sneezes and coughs, and 
shows a general Weariness similar to that imparted by a cold in the 
head. Chills or chilliness, followed by fever which may reach 104° 
or more, and a variable degree of prostration and drowsiness are 
present at the onset. During this period prodromal, urticarial or 
erythematous rashes appear, and an enanthem is almost constant. 
The latter is of two types ; an erythema of the tonsils, fauces, pharynx 
and hard palate, in the last named region often taking the form of 
puncta ; and the so-called Koplik's spots. These spots accredited to 
Koplik who described them in 1896, were first noted in the literature 
by Filatow a year earlier, but actually Flindt had observed them 
many years before either. They are bluish white minute dots on the 
mucosa of the cheek, prevailingly opposite the molars, and may be 
observed in about ninety percent, of all cases two days before the 
appearance of the eruption. They may also occur anywhere else 
in the mouth. They are gone by the time the exanthem sets in. 

About four days after the onset the characteristic rash is first 
noted, and it reaches full bloom in forty-eight hours more. During 
this period the fever and catarrhal symptoms are most marked. 
The forehead and temples are first affected, then the face, neck, 
trunk, upper and finally lower extremities, in the order mentioned ; 
even the hands and feet are covered with a disseminated, symmetrical 
erythema. Upon close study the exanthem is found to be composed 
of dusky, red, yellowish-red, or somewhat violaceous macules, 
grouped either in no particular order, or in segments of circles. In 
their midst areas of normal skin show through. The lesions are 
flat, or slightly elevated, one millimeter to a centimeter in diameter, 
and disappear on pressure. At times, too, there may be veritable 
papules, some of which feel shotty. The face is slightly edematous. 
General glandular swellings often occur. 

Course. The onset is relatively gradual, the fever rising slowly 
and reaching its f astigium on the fourth day, beginning its descent 
on the fifth, and becoming normal by the sixth or seventh, but 
occasionally not until the tenth or twelfth. On the sixth day the 
eruption starts to fade, beginning on the face and proceeding in the 
order of its evolution. Desquamation accompanies this process. 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 67 

The scales are always fine and branny, and cease to form, as a rule, 
after about a week, but may remain for ten or twelve days. 

Varieties. Morbilli may be mild, severe or hemorrhagic, the 
first two depending upon the height of the fever and general symp- 
toms; the last being caused by minute cutaneous hemorrhages into 
the lesions. This form is also called black measles, is rare, severe 
and often fatal. 

Complications and Sequelae. The commonest complications 
are pneumonia or bronchopneumonia, while otitis media, renal and 
cardiac diseases rarely develop. Noma, erythema nodosum, lupus 
vulgaris, impetigo, erysipelas and furunculosis at times follow 
measles. At times, too, pulmonary tuberculosis is a sequela. Both 
the complications and sequelae vary in different epidemics. 

Diagnosis. In the prodromal stage the coryza, photophobia, gen- 
eral symptoms and cough are suggestive, while the presence of 
Flindt's (i. e., Koplik's) spots is pathognomonic. These spots must 
be differentiated from aphthae, painful, small, yellowish ulcers sur- 
rounded by a fine red areola, usually seen on the mucous surface of 
the lower lip and tip of the tongue on both of its surfaces. Aphthae 
have nothing to do with measles and are probably a form of herpes. 
Later on scarlatina, German measles, Duke's disease, typhus and the 
early stages of variola, particularly when papules are present, must 
be ruled out. (See these diseases below.) Multiform erythema at 
times resembles measles. The absence of fever and Flindt's spots, 
and the comparative health of the patient exclude this disease, and 
these points, plus the history of drug ingestion, aid in the diagnosis 
of the copaiba rash. 

Etiology and Pathogenesis. Measles is a disease of childhood. 
It may occur in the first year of life, in which respect it differs from 
scarlatina which is rarely seen before the third year, and almost never 
in nurslings. The contagion is unknown; exposure must be direct 
and infectiousness persists for three weeks after the onset. The 
average incubation period is eleven to fourteen days and the disease 
confers permanent immunity. 

Prognosis. Uncomplicated measles is not a serious disease. 
Through the pneumonia which may accompany it and the tuberculosis 
which may follow it, however, the mortality is raised enormously, 
and, as Osier states, it ranks third in death rate among the eruptive 
fevers. In institutions for young children Holt mentions that the 
mortality varies from fifteen to thirty-five percent., while the average 
mortality is from four to six percent. 



68 DEKMATOLOGY 



GERMAN OR FRENCH MEASLES 



Synonyms. Rubella, Rubeola. Epidemic Roseola; German, 
Rotheln; French, Rubeola. 

Definition. Rubella is an acute epidemic exanthem having some 
of the characteristics of measles, and some of scarlatina, which runs 
a short, mild course. 

Symptoms. The disease appears after a few hours of illness, 
occasionally with a mild nasal catarrh, or without prodromata, the 
first symptom being the rash, with the appearance of which the 
temperature reaches 100° to 101°. The rash starts on the face, 
spreads to the neck, torso, upper and finally lower extremities. It 
is either morbilliform or scarlatinoid in character, bright or dusky 
red, itchy, and occasionally papular, but usually macular. It is 
symmetrical, disappears on pressure, and at times the papules feel 
shotty. At the height of the exanthem the post cervical glands are 
usually markedly enlarged. 

Course. After a vague prodromal period, or without any, the 
rash appears with a low fever. These last a day or two, the rash 
covering the body within twenty-four hours and fading in the order 
of its evolution. Slight, fine or coarse desquamation follows; or at 
times none at all. When present, the scaling is complete within a 
week. 

Varieties. Exceptionally the disease is severe, the temperature 
reaching 104°. 

Complications and Sequalae. There are none. 

Diagnosis. Sporadic cases are almost impossible to recognize 
with certainty. In epidemics the diagnosis is easy. Measles and 
scarlet fever may be confused with it at the onset; but the severer 
systemic symptoms of both, combined with the catarrh and Elindt's 
spots in measles, and the angina in scarlet, in addition to their 
characteristic subsequent course, should render any doubt of 
short duration. Eorchheimer in 1898 described an enanthem 
in rubella, consisting of minute, red puncta on the uvula and soft 
palate, which are supposed to be present in the first twenty-four 
hours. 

Etiology and Pathogenesis. The contagion is not known but 
is transmitted by direct contact, mostly during the five days follow- 
ing the onset. The incubation period is about three weeks. Im- 
munity is apparently permanent. 

Prognosis. Rubella is never fatal or even serious. 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 69 

duke's disease 

This ill defined syndrome, also known as the fourth disease, was 
originally described by Duke and has not been accepted as a clinical 
entity. It is mild, accompanied by a fever of about 101°, slight 
glandular enlargements and an exanthem. The rash appears sud- 
denly, rapidly involves the whole body, resembles that of scarlet 
fever, but is a more vivid red, lasts a day or so, and fades without 
marked scaling, if any at all. The period of incubation is given at 
from nine to twenty-one days. 

SCARLATINA 

Synonyms. Scarlet Fever, Scarlet Rash; German, Scharlach; 
French, Scarlatine. 

Definition. Scarlatina is an acute infectious disease character- 
ized by an exanthem, fever and angina, and a severe systemic reac- 
tion. 

Symptoms. A sudden onset with chills or only chilly sensations, 
in adults, and convulsions in children, sore throat, severe headache, 
vomiting and a sharp rise in temperature to from 102° to 105° 
characterize the beginning of scarlatina. Within twenty-four hours 
a rash breaks out and the skin itches. In a typical case the patient 
is either apathetic or agitated, but dull, the cheeks are flushed, the 
ears red and edematous, the eyes bright and the area about the lips 
pallid, the pallor intensifying the flush of the cheeks. On the neck 
and chest are seen minute, deep red puncta, some macular, others 
slightly raised against a lighter, diffuse scarlet background. If the 
upper extremities be held so that the elbow flexure and backs of the 
fingers may be seen together, the former is found covered with a 
rash like that on the neck, the latter with an erythema studded with 
minute elevations, reddish or whitish in color, and resembling tiny 
miliaria, but actually being true vesicles, the pathology of which 
has been excellently studied by Egon Rach of Vienna. A scarlet 
enanthem covers the pharynx. The entire buccal mucosa is edem- 
atous, the tonsils enlarged, at times enormously so, and occasion- 
ally covered with dull grey or yellow superficial ulcerations. These 
findings account for the pains in the throat and occasional dysphagia. 
The tongue is furred and the swollen red papillae projecting through 
the coating give this organ an aspect which justifies the term " straw- 
berry " tongue. The fever is high. All of these symptoms and 
signs are referable to the first day or so of scarlatina. Within an- 



70 DEKMATOLOGY 

other day the body is entirely covered with the eruption which main- 
tains the general features seen in the early stage on the neck. The 
throat is worse, the general discomfort, dysphagia and prostration 
more intense, and the fever high with slight morning remissions. 
The cervical glands are enlarged. During this period the tongue 
loses its coating, becomes generally red and glistening, but the 
papillae remain swollen. Thus the tongue roughly resembles a rasp- 
berry. The rash starts to fade, desquamation sets in, the scales 
being furfuraceous, coarse or laminated, and at times actual epi- 
dermal casts of the fingers, toes, hands and feet are thrown off. A 
characteristic of the rash at its height is its disappearance on pres- 
sure, the ischemic area thus left being not white, but yellowish- 
brown, pale, or subicteric in color. 

Course. The onset is sudden, the rash fully developed within 
two to three days, and at this time, or at the most within a week, it 
commences to fade. Scaling begins and is usually complete within 
three weeks from the beginning of the disease, the process ending 
on the palms and soles. At times six weeks are required for 
desquamation. The fever usually falls with the involution of the 
rash, and the patient goes on to recovery unless one of the numerous 
complications arise. 

Varieties. There is a milder form of the disease in which the 
rash remains limited to the neck ; a form in which only throat symp- 
toms are present; or a pharyngeal form in which three weeks later 
nephritis develops. The last two are called scarlatina without ex- 
anthem. A variety is known with severe central nervous symptoms, 
delirium, stupor, restlessness, headache, convulsions and hyper- 
pyrexia. At times the rash is hemorrhagic. A form called surgical 
scarlatina has its starting point about wounds, but otherwise runs 
the usual course. Finally, there is a fulminating variety which 
ends fatally from intoxication, within a day or two of the onset. 

Complications. During the eruptive period albuminuria with 
casts is often present. This is toxic in origin and not serious. Af- 
ter the third week, however, true nephritis, at times severe and 
causing uremia, may appear. This usually clears up, but frequently 
becomes chronic. Otitis media, mastoiditis, suppurative cervical 
adenitis, articular rheumatism, endocarditis and rarely, chorea fol- 
low scarlet. Occasionally, diphtheria or varicella are complicating 
diseases. Immunity is usually conferred by one attack, but recur- 
rences, though rare, have been observed, as have been relapses and 
re-infections. 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 71 

Diagnosis. The diagnosis is easy in typical cases. The sudden 
onset with chills in adults and convulsions in children, the throat 
symptoms,, tongue and rash are all sufficiently distinctive. During 
the early stage a leukocytosis is present, an eosinophilia, and in the 
polymorphonuclear leukocytes, Dohle's bodies, originally regarded by 
him as the cause of scarlatina, are found. These are not path- 
ognomonic, but never occur in toxic or drug rashes, and are thus of 
corroborative value. Scarlet must be differentiated from measles, 
Rotheln, toxic rashes, drug rashes and the scarlatinoid erythrodermas. 
In all of these conditions either the abrupt onset or throat symptoms 
are wanting. In measles, the catarrah and Flindt's spots are of 
value; in Rotheln, the onset is mild; in toxic rashes, one of the 
numerous causes of these may be ascertained; in drug rashes, a 
history of medication may be elicited and Dohle's bodies are absent. 
In the scarlatinoid erythrodermas the pharynx is rarely involved, 
the systemic symptoms are mild, and subsequent attacks are frequent. 

In the first ten days of the disease the Wassermann reaction is 
at times present. This was once thought to be of significance, but 
did more to bring the Wassermann test into disrepute than to explain 
or help to diagnosticate scarlet, and after all it possibly only indi- 
cated that the case was one of scarlet in a syphilitic. Koessler did 
some unconvincing work on complement fixation tests in scarlet using 
the glands of scarlet patients as antigen. Bela Schick of Vienna 
regarded as a diagnostic point in the early stages the ease with which 
hemorrhages could be produced by lightly pinching the skin. The 
author has found it an equally prevalent sign in all exanthemata, 
whether infectious or toxic. This is in line with Leede's observation 
that a tourniquet above the elbow produces petechiae below the con- 
striction in scarlet fever patients. Anyone who has administered 
arsphenamin or taken blood from the veins at the elbow flexure must 
have observed this purely mechanical phenomenon in all people. 
In the last analysis the diagnosis of scarlatina rests upon a knowledge 
of its clinical features. 

Etiology and Pathogenesis. About twelve years ago Mallory 
described the cyclasterion scarlatinale, an alleged protozoon pre- 
sumed to be the pathogenic agent of the disease. It is a body found 
in the malpighian cells of the epidermis, and is either an artifact or 
a cell degeneration. The streptococcus, too, has been regarded as a 
causative factor. There are no good grounds for this, and the theory, 
from what we know of streptococci, seems unlikely, since these or- 
ganisms are not known to confer immunity, an experience to which 



72 DEEMATOLOGY 

scarlet would be an exception. Unquestionably, however, tbe 
streptococcus causes many of tbe purulent complications and sequelae 
of the disease. Children seem more subject to the malady than 
adults, but this is due to exposure in schools and institutions, and a 
large proportion of adults who have escaped the disease in childhood, 
get it when exposed later in life. Infants under a year old are 
rarely infected. The contagion must be in the secretion from the 
nose and throat, as the communicability of the disease is greatest 
during the anginal stage. The belief in the infectiousness of the 
scales has been practically abandoned. Even children whose 
desquamation is not complete are now allowed to associate with 
their fellows, provided the throat is well. Transmission through a 
third person is rare, but through infected foods such as milk is com- 
mon, and this mode of conveyance has accounted for many scourges. 
The infection of the foods probably takes place through contamina- 
tion with pharyngeal ejecta of the diseased. Sporadic cases of 
scarlet are not infrequent, but the disease is prevailingly an epidemic 
one. The incubation period is from three to five days, the average 
being four. 

Prognosis. Scarlatina is a grave disease, partly because of the 
numerous severe uncomplicated forms, partly because of the many 
serious complications. In children under five years of age the mor- 
tality rises to thirty percent. ; in older children and adults the 
average mortality is close to ten percent., but this varies with the 
epidemic, the extreme limits being from three to forty percent. 

VARIOLA 

Synonyms, Small Pox, the Pocks ; German, Blattern, also 
Pocken ; French, Petite Verole. 

Definition. Variola is an acute eruptive fever running a definite 
course divided into two stages, and characterized by severe general 
symptoms and a vesiculo-pustular eruption. 

Symptoms. The invasion in small pox is sudden. Severe 
frontal headache, pain in the back and limbs, a chill or rigor, and in 
children, convulsions, and an abrupt fever of 103° or 104° distin- 
guish the onset. Vomiting and delirium are frequently seen. The 
skin is dry, the face flushed, eyes bright, expression anxious, and the 
patient is restless. A morbilliform or scarlatinoid rash, often gen- 
eralized and occasionally hemorrhagic appears. Its localization may 
be anywhere on the body, but its favorite sites are the lower abdo- 
men, inner aspect of the thighs, the flanks and axillae. The first 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 73 

stage lasts three or four days, when the temperature falls, the sys- 
temic symptoms vanish, the early rash fades and the true rash ap- 
pears. On the seventh day the fever begins again to rise, reaching 
its maximum on the ninth or tenth day with the height of the new 
eruption's development. The second stage is now in full swing. 
During this period the eruption is either discrete or confluent. 
Both forms begin at the hair line of the forehead and on the wrists 
as small red papules. 

The Discrete Variety. Within a day the papules spread to the 
rest of the face and extremities, particularly the palms and soles, 
rarely involving the trunk in profusion. They feel shotty, become 
vesicles on the fifth or sixth day, and present a depression or umbil- 
ication. On the eighth day they turn into pustules, the umbilication 
disappearing. They are yellow or gray and surrounded by a deep 
red areola of inflammation. It is at this point that the second rise 
in fever, mentioned above, takes place. The changes in the lesions 
occur first on the face, and then elsewhere in the order of their 
evolution. Edema is caused by the inflammation about the pustules, 
and since the latter are numerous upon the face, it becomes swollen 
and distorted. By the eleventh day the second fever drops, the 
pustules rupture and crust, and convalescence sets in. In the dis- 
crete form scarring rarely occurs. Vesicles often are seen in the 
mouth, and even the larynx may be involved. 

The Confluent Variety also begins with isolated papules as men- 
tioned, but they are more numerous than in the discrete form and 
when the pustules develop they run together so that the face is 
virtually a diffuse pustule. Coalescence is never seen on the body. 
Otherwise, the course follows that of the discrete type, save that the 
fever is higher, the mortality greater, the swelling of the face more 
marked, and the prostration worse. Salivation and cervical gland 
swellings are frequent. Desiccation begins on the twelfth day, and 
the process of scarring is complete in three or four weeks. The last 
sites to return to normal are the palms and soles on which the pustula- 
tion is nearly as profuse as on the face, and the healing process de- 
layed because of the depth of the epidermis overlying the lesions. 
Depressed cicatrices remain. A leukocytosis is present in variola. 

Course. The disease begins abruptly. After an incubation 
period averaging nine days there is a rise in temperature accom- 
panied by an erythema which fades rapidly, to be replaced by the 
pustular exanthem, at the height of which the fever again rises after 
a brief normal period. The patient gets well or dies, subject to the 



74 DEKMATOLOGY 

variety and severity of the infection, or the incidence of some of 
the fortunately infrequent complications. The entire course of a 
severe infection which leads to recovery is complete within four 
weeks. 

Varieties. There are two main varieties of small pox, the true 
and the hemorrhagic. The true is divided into the discrete and 
confluent already described ; the hemorrhagic into two varieties, the 
purpura variolosa, and variola hemorrhagica pustulosa. 

Purpura variolosa is the black small pox. It begins as ordinary 
variola, but in three days a hemorrhagic eruption appears starting 
with an erythema, particularly in the groins. The face is enor- 
mously swollen, the palpebral fissure almost being obliterated by the 
edema. The conjunctiva and the buccal mucosa are the site of 
hemorrhages, and bleeding may occur on other mucous surfaces, the 
blood appearing in the urine, sputum, stools, vomitus, etc. In some 
cases the skin is actually purple from subcutaneous bleeding. These 
cases are fatal as a rule. 

Variola hemorrhagica pustulosa is ordinary small pox in which 
hemorrhages occur into the pustules. The purpura variolosa is 
usually fatal before the pustular stage develops. 

Complications. Laryngitis and bronchopneumonia are frequent 
complications. Formerly, iritis and keratitis were often observed, 
but these untoward results are rare now since the hygiene of the eyes 
in small pox has been improved. After confluent variola the skin 
is pitted. 

Diagnosis. In the first stage measles and scarlet must be ex- 
cluded. Flindt's spots, the coryza and the milder systemic symp- 
toms of measles, the presence of angina and the strawberry tongue 
of scarlet, the peculiar distribution of the early exanthem of variola, 
and the severe systemic symptoms are the factors on which must be 
based the differential diagnosis. In the period of the second rash 
small pox must be differentiated from varicella, acute pemphigus and 
the varioliform secondary syphiloderm. Varicella occurs mostly in 
children, the symptoms are milder, the eruption comes in suc- 
cessive crops, papules and pustules appearing together. Pemphigus 
often begins with severe systemic symptoms, but the lesions are blebs 
arising prevailingly upon non-inflamed skin, and are not umbilicated. 
The syphiloderm in question is of gradual onset, longer duration, ac- 
companied by milder symptoms, general adenopathies, and the Was- 
sermann reaction is present. 

Etiology and Pathogenesis. The nature of the infectious agent 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 75 

is unknown. That it is present in the secretions, in the vesicle con- 
tents, pustules, crusts and fomites is undoubted. Lady Mary Whort- 
ley Montague's inoculation and the work of Jenner proved its trans- 
missibility, as well as the prophylactic value of milder attacks pro- 
duced by the human or bovine virus which must be similar if not, 
indeed, identical. The prevention of the disease through vaccina- 
tion, the mild course of the disease in the few vaccinated individuals 
who sustain subsequent infections, the practical elimination of var- 
iola in districts in which vaccination laws are strict, arouse astonish- 
ment at the fanaticism of those who are opposed to this simple and 
harmless form of prophylaxis. The contagion has not yet been dis- 
covered, although we know exactly where it is situated, but we do 
know that its virulence may be ameliorated by vaccination. Sex, 
age, race, even general health have no influence upon the incidence 
of the disease. Although variola is an epidemic disease, it smoulders 
in foci throughout the world. The high fever and general symptoms 
in the pustular stage may, in part, be accounted for by secondary 
infection with pyogenic bacteria. 

Prognosis. The mortality varies from twenty-five to thirty-five 
percent, in different epidemics. Confluent variola and purpura 
variolosa are the severest forms, and these as well as hyperpyrexia, 
and laryngitis, account for the greatest number of deaths. Early 
death in variola usually occurs on the third day; late death on the 
eleventh or twelfth. 

VARIOLOID 

Varioloid is mild small pox modified by previous vaccination. An abrupt 
onset characterizes the disease, with general symptoms resembling those of 
small pox. The papules which rapidly become pustules appear on the 
third day, the temperature which may rise to 103° falls when the rash ap- 
pears. The entire course of the disease is about ten days. Pitting is rare. 
Varioloid, when transmitted to the unvaccinated, causes true small pox. 

VACCINIA 

This is the small pox lesion artificially induced by vaccination. Its 
characteristics are too well known to need mention in this book. At times 
auto -inoculation, as mentioned in connection with dermatitis medicamen- 
tosa, may cause vaccinia pustules to develop elsewhere in the body. 

VARICELLA 

Synonyms. Chicken Pox; German, Windpocken, Wasserpocken, 
Spitz Blattern; French, Variolette. 

Definition. Varicella is an acute eruptive disease the cutaneous 
lesions of which develop at the onset and recur in crops. 



76 DERMATOLOGY 

Symptoms. The onset is sudden, the fever rising as high as 104° 
at times, usually, however, to 100° or 101°. Frequently the disease 
is afebrile. A certain amount of malaise is present. The rash ap- 
pears at once, starting on the face, involving the extremities and 
trunk to a variable extent. The conjunctiva and buccal mucosa are 
sometimes included in the eruption ; the palms and soles never. The 
first lesions are shotty papules which rapidly become umbilicated 
vesicles, the size of a pea and surrounded by a pink areola. In a 
day or so after their appearance they become turbid, and in another 
day begin to desiccate. Successive crops appear, and thus the erup- 
tion has a polymorphous character, the elements of which are 
papules, vesicles, pustules, crusted lesions and pink macules where 
the crusts have fallen off. Scarring is rare. The temperature lasts 
a day or so, as a rule, and in a week or ten days the patient is 
well. 

Diagnosis. The two important conditions from which varicella 
must be differentiated are variola and impetigo contagiosa. Unless 
the systemic symptoms of varicella are severe, no confusion between 
this condition and small pox should arise. The absence of the pro- 
dromal rash, backache, headache, etc., serve to rule out variola. Im- 
petigo contagiosa is a pustulo-bullous eruption in which the bullae 
are infrequently seen because of their delicate structure, which 
causes them to rupture early. At their site a honey-yellow crust 
develops, unless the lesions are very much irritated and bleed, in 
which case the crust becomes brown. The bullae when present are 
never umbilicated. Thus, during the bullous stage no confusion 
between impetigo and varicella is possible. It is only during the 
stage of desiccation that there may be any doubt. But the absence 
of papules and the presence of some associated underlying cause of 
impetigo, such as pediculosis, scabies, urticaria, as well as the ab- 
sence of fever and systemic symptoms, should clear up the problem. 

Etiology and Pathogenesis. The cause of the disease is un- 
known, but children are more frequently attacked than adults. The 
incubation period is ten days or so. 

Prognosis. The prognosis is invariably good. 

In discussing the group of diseases with exanthems in which the 
latter are secondary considerations, only the cutaneous lesions and 
such other points as are of importance etiologically or diagnostically, 
will be mentionel. Brevity demands the exclusion of general clinical 
descriptions ; nor do these belong in a work on skin diseases. 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 77 



TYPHOID FEVER 

The characteristic rash of this disease is a roseola which appears 
between the seventh and tenth days. It starts upon the abdomen 
and back and consists of a few isolated lesions, or they may be very 
numerous and occasionally occur elsewhere on the body, particularly 
on the arms and thighs, less frequently on the forearms and legs, and 
almost never elsewhere. The individual lesion is a minute, hyper- 
emic, slightly raised macule, which disappears upon pressure, and 
has a faint rose to a dark red shade. When very extensive and dense 
the rash somewhat resembles measles. The raised spots occur in 
successive crops, a few in each group until the period of deferves- 
cence. N"ew eruptions appear with recrudescences or relapses of the 
disease. At times the spots are hemorrhagic. Occasionally desqua- 
mation follows the exanthem, but as all prolonged fevers are followed 
by dryness of the skin and hence, scaling, the significance of this 
process in typhoid cannot be accurately interpreted. 

Diagnosis. The general points upon which the diagnosis rests 
are the history of the case, the general clinical symptoms and signs 
of typhoid, the positive blood culture in the early stages of the dis- 
ease, the Widal reaction later on, and the leukopenia and relative 
lymphocytosis seen in typhoid. Measles, the typhus exanthem, and 
the syphilitic roseola resemble the typhoid rash. Measles may be 
ruled out by the absence of coryza, Flindt's spots, and the presence 
of the positive signs of typhoid. The differentiation from typhus 
will be considered below. The syphilitic roseola is ruled out by the 
absence of the Wassermann reaction and the positive signs of syphilis. 

Etiology. This rash may be due to cutaneous emboli of typhoid 
bacilli, for it appears only in the bacteremic stage of the disease, 
or as a local cutaneous reaction to the bacteria or their toxins, repre- 
senting an allergic phenomenon. 

Other Rashes Seen in Typhoid. During the febrile stage 
miliaria, later on furuncles, may be observed, and after prolonged 
typhoid, bed sores are encountered. Post febrile alopecia is frequent, 
and the nails become transversely ridged, as they do however after 
all prolonged fevers. The absence of herpes in typhoid is note- 
worthy. On the fauces Bouveret's ulcers appear. 

TYPHUS FEVER 

The onset is abrupt with a rigor, chills, chilliness, headache, pains 
in the back and legs, prostration, bronchitis, and a fever often of 



78 DERMATOLOGY 

105°. After from three to five days the eruption appears on the 
abdomen, spreading thence to the chest, face and extremities. It 
consists of two elements: a diffuse blush and a roseola somewhat 
darker, which rapidly becomes hemorrhagic. The skin is dry. 
There are associated delirium, prostration and the general symptoms 
of typhus. The rash fades after a week and desquamation begins 
after three weeks. The systemic symptoms last for a fortnight when 
the temperature falls critically. 

Diagnosis. This disease may be confounded with typhoid, 
measles and black small pox. The positive signs of typhoid, the 
sudden onset of typhus, the absence of the Widal reaction, and the 
negative typhoid and positive typhus blood culture and serum reac- 
tion, should suffice to prevent error. When the typhus rash is not 
profuse it may resemble measles. Here the prodromata of the lat- 
ter disease, the buccal spots, and the severer onset of typhus, with its 
characteristic fever curve and blood findings, are the diagnostic points 
to be emphasized. Confusion with variola is possible only for the 
first few days before the appearance of the pustules. 

BRTLl/s DISEASE 

This disease was originally described by Nathan Brill and re- 
garded as due to auto-intoxication until Plotz in 1914 isolated a 
bacillus which he found also caused typhus, and by a series of excel- 
lent investigations established the identity of these two diseases. 
The syndrome is distinctive. After a brief period of malaise, asso- 
ciated with severe headache and constipation, the fever rises abruptly 
to from 103° to 105°, and a rash develops which is seen on the belly, 
back, chest and extremities. It consists either of a few dusky rose 
spots or a morbilliform eruption on a dusky red background. The 
fever drops critically in a week to ten days, the rash fades and the 
patient is well. Body lice are associated with the disease, and the 
bacillus gains access to the host through the parasite's bite. The 
disease must be differentiated from typhoid and measles along the 
lines laid down in connection with typhoid and typhus. 

EOCKY MOUNTAIN" SPOTTED- EEVEE, 

This disease is endemic in the Rockies, in Oregon, Montana, Utah and 
Idaho. It begins suddenly in the Spring, with severe general symptoms, 
a sharp rise in fever to 105° or 106°, which remains high for about twelve 
days and gradually declines. At the onset a rash appears on the wrists, 
back and ankles. It extends gradually, resembling a toxic purpuric er- 
ythema, A diffuse yellowish background sets off the eruption. From four 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 79 

to ten percent, of the patients die. Recovery in favorable cases is complete 
in three weeks. 

CEREBROSPINAL MENINGITIS 

This disease is also known as spotted fever from a punctate rash 
found in many cases. The eruption is usually roseolar or purpuric, 
and covers the face, particularly the ears, during the first twenty- 
four hours of the disease. The diagnosis is made by the concomitant 
signs of meningitis, and the discovery of the meningococcus in the 
spinal fluid. 

SEPSIS 

In sepsis and bacterial endocarditis, usually when caused by one 
of the numerous strains of streptococci, various eruptions are seen. 
These are petechial, toxic or erythematous in character, and occasion- 
ally purulent. The petechiae may be found anywhere, but favor the 
wrists, ankles, conjunctiva and buccal orifice. They are minute, 
bright red spots which persist upon pressure and rapidly turn brown 
and fade. They appear in successive crops. The erythemas are due 
to bacterial toxins. The pyodermas are due to emboli which cause 
local, usually subcutaneous suppurations. Erythema nodosum is 
sometimes observed. The diagnosis depends upon a positive blood 
culture, as well as the clinical signs of sepsis, such as the fever curve 
and cardiac involvement. 

FOLLICULAR TONSILITIS 

Not infrequently a faint scarlatinoid rash appears on the neck and 
chest in the first days of follicular tonsillitis, particularly when marked 
systemic symptoms are present and high fever. To be absolutely certain 
that the case is not one of scarlatina is impossible. Frequently enough 
cases of this type get apparently well in a day or so, and three weeks later 
an acute nephritis develops. Although there are no certain grounds for 
a differential diagnosis between scarlet and the tonsillar erythema, the fact 
remains that the majority of these cases are not scarlet. Nevertheless, the 
greatest circumspection is necessary both as to diagnosis and prognosis. 

PERTUSSIS 

The effort of coughing causes a rupture of the minute vessels in the 
mucosa below the togue, on the lips, and in the conjunctiva. The result 
is the formation of petechiae. 

MUMPS 

Before the swelling of the parotid glands, thus during the prodromal 
stage of mumps, a small red circle is seen on the buccal mucosa opposite 
the upper molars. This corresponds to the opening of Stenson's duct, and 
is caused by a swelling and inflammation about its aperture. It is of value 



80 DERMATOLOGY 

in foretelling beginning cases during an epidemic. I have once seen this 
phenomenon in a child at the onset of glandular fever. 

ENCEPHALITIS LETHARGIC A 

Herpes simplex of the face has been observed. 

PURPURAS 

Purpura is an eruption due to hemorrhages into the skin. Lesions 
varying from punctate to coin size are called petechiae ; large, irreg- 
ular ones are ecchymoses ; when linear in arrangement, either through 
linear trauma, or by an accident of distribution, vibices are formed ; 
and when bleeding takes place into vesicles or bullae, these are 
qualified by the adjective hemorrhagic. At times, blood collects 
into large masses the size of a nut, or even greater, and such accumu- 
lations are termed ecchymoses. Purpuras fall into three classes, — 
mechanical, symptomatic and primary. 

Mechanical Purpura. This form is due to some obstruction in return 
circulation. Thus, during or after obliterating phlebitis, particularly of 
the femoral vein, purpuric outbreaks occur below the level of the clot, and 
are increased by overtaxing the compensatory circulation. In connection 
with varicose veins, particularly of the lower extremities, a similar con- 
dition is seen, partly due to endophlebitis and partly to a fragility of the 
cutaneous veins. Thus, associated with dermatitis and leg ulcers, petechiae 
and even ecchymoses are observed. 

Symptomatic Purpura. In the course of infectious diseases (see Exan- 
themata), intoxications (see Drug and Toxic Rashes and Multiform Er- 
ythema), and in cachectic diseases such as leukemia, tuberculosis, tabes, 
Hodgkin's disease, marasmus, etc., purpuric outbreaks occur. 

Primary Purpura. There are many varieties of this disease as the fol- 
lowing table indicates: 

I. Arthritic: 

1. Purpura Simplex. 

2. Purpura or Peliosis Rheumatica. 

3. Henoch's Purpura. 

II. Purpura Hemorrhagica. 
III. Purpura Neonatorum. 
IV. Hemophilia. 

V. Scurvy. 

Purpura Simplex is more frequent in children than in adults. 
It is usually, but not always, febrile; arthritis is frequently but 
not invariably present. The spots appear in crops, are petechial, 
favor the legs, and are at times seen on the trunk and upper ex- 
tremities. 



DRUG ERUPTIONS, EXANTHEMATA AND PURPURAS 81 

Purpura Rheumatica, also known as Peliosis Rheumatica and 
Schonlein's disease, is sudden in its onset. It starts with pharyngitis 
or tonsilitis, and is usually seen in males in the third decade of life. 
Multiple arthritis, fever, and a certain degree of prostration accom- 
pany the disease. The lesion is not purely purpuric, but admixed 
with urticarial, multiform erythematous and nodular erythematous 
elements, as well as hemorrhagic bullae and vesicles. The eruption 
tends to localize itself about the affected joints but may occur any- 
where, and the angioneurotic lesions favor the eyelids and face. 

Henoch's Purpura. This disease has several marked character- 
istics besides the cutaneous lesions which are either purpuric or those 
of erythema multiforme. They have no definite localization. 
Relapses are frequent. The other features are arthritis, mucous 
hemorrhages and gastro-intestinal crises, attended by colic, vomiting 
and diarrhoea. The visceral crises are of great diagnostic im- 
portance. Cholecystitis, and particularly appendicitis, are simu- 
lated, and many an appendix has been removed from people suffering 
from Henoch's purpura. Hemorrhagic nephritis occasionally fol- 
lows this disease. 

Purpura Hemorrhagica is also known as morbus maculosus of Werlhon 
and is generally seen in young and delicate girls. After a few days of 
malaise the purpura breaks out in the form of petechiae and ecchymoses. 
Nose bleeds, hematuria and hematemesis develop. At times so severe a 
secondary anemia is brought about as to be fatal, and occasionally cerebral 
hemorrhages occur which almost invariably cause death. 

Purpuras in the Newborn are due to syphilis, or to an unknown cause. 
In the former type, the child may seem healthy at birth. In any case, 
shortly after this event cutaneous and mucous hemorrhages and bleeding 
from the stump of the cord appear, and the infant becomes jaundiced. A 
great number of these patients die. The second type is known as morbus 
maculosus neonatorum, and is always fatal. It begins during the first 
few weeks of life with cutaneous hemorrhages, and bleeding from the 
nose, mouth, cord, intestines, kidneys and lungs. 

Hemophilia, This is an hereditary disease, transmitted to males 
through females, and the Mendelian law, as shown by Ottenberg, 
governs its distribution in the family. Hemophiliac males, if they 
marry sound women, do not transmit the disease to their sons. 
Females born of hemophiliac males may transmit the bleeding 
tendency to their sons, but do not invariably do so. Bleeders are 
found almost wholly among Anglo-Saxons and Teutons, but no race 
is absolutely immune. Although the commonest symptoms are pro- 
fuse bleeding from the mucous membranes, or from trifling injuries, 



82 DERMATOLOGY 

arthritis of the knees and elbows has been frequently noted, but- 
even the smaller articulations may be involved. 

Scurvy. This disease, also called Scorbutus, occurs in two forms, 
the infantile and adult. In infantile scurvy, or Barlow's disease, 
tenderness and swelling of the bones, chiefly the femurs, ecchymoses 
about the joints and hemorrhages in the pharynx are observed. The 
children seem to be paralyzed and although the involved bones do 
not hurt spontaneously, they are exquisitely tender. The swelling 
and tenderness are due to subperiosteal and epiphyseal hemorrhages. 

Adult scurvy begins insidiously with weakness, swollen and bleed- 
ing gums, hemorrhages into the buccal mucosa, ecchymoses on the 
arms and trunk, largely near the hair follicles. The lesions may 
also be petechial. Subperiosteal hemorrhages with swelling and 
tenderness are co mm on. Bleeding from various mucous surfaces 
may occur. 

Etiology. The causes of purpura are numerous. The arthritic 
forms are associated with rheumatism. The etiology of Purpura 
Hemorrhagica is not known. One form of purpura neonatorum is 
due to syphilis : the origin of morbus maculosus neonatorum has not 
been ascertained. Hemophilia is hereditary in the scientific sense of 
the word. Scurvy is caused by faulty diet, specifically the lack 
of vitamins in fruits, fresh vegetables and potatoes. 

Therapy. The arthritic forms should be treated as rheumatism. 
The syphilitic variety of the newborn must be treated as syphilis. 
Hemophilia is best controlled by the transfusion of blood, or at 
least the intravenous or subcutaneous injection of suitable human 
sera. Emsheimer has successfully treated Werlhofi's disease by 
intramuscular injection of whole blood. Scurvy yields rapidly to 
fruits, potatoes and legumes, followed by tonics. Local treatment 
is useless. 

Prognosis. With the exception of purpura hemorrhagica, pur- 
pura of the newborn and hemophilia, the prognosis as to longevity 
is good, and as to cure is fair. Hemophilia is not necessarily, in 
fact not frequently fatal, but unless the new methods of treatment 
prove as promising as is hoped, the outlook for a cure will be as 
fruitless as in the past. Scurvy is always curable if treatment is 
timely. 




Fig. 6. IODODERMA 

This is the bullous type of iodine rash, resembling variola, 
varicella and pemphigus (Fig. 18). It differs from all of these 
in the fact that the bullae turn into granulomata, and in the 
clinical course of the disease. Iodine is found in the urine. 



•S to 





Fig. 8. BROMODERMA TUBEROSUM (CF. FIGS. 
8 AND 9) 

Cribriform abscesses, crusting and vegetation are 
the features of these lesions which are brownish or 
purple in hue, crusted and tender. They look like 
blastomycosis and sporotrichosis, which bacterio- 
logic study excludes. Bromine is found in the urine. 



CHAPTEK VIII 

DISEASES OF THE CUTANEOUS VESSELS; 
TELANGIECTASES ; GANGRENE 

Cutaneous vascular diseases lead to changes which differ accord- 
ing to the size of the vessels involved, the number, and the nature 
and extent of the involvement. As in other organs, the vessels 
may dilate, contract, and become occluded, increased or decreased 
in number. The pathogenesis of these changes is varied; the alter- 
ations wrought by them upon the s£in are comparatively restricted. 
Thus, this group of diseases is an example of the relative limitation 
of the morbid responses the skin is capable of displaying to unre- 
lated causes. In other words, among these diseases the doctrine of 
cutaneous reactions (see Chapter III) is nicely illustrated. 

When capillaries dilate they show through the epidermis as minute 
streaks reddish or purplish in tone, according to whether they con- 
tain aerated or used blood. Such vessels are telangiectatic and 
the condition is known as telangiectasis. If, in addition to telan- 
giectasis, there be a local extravasation of blood, an element of 
purpura is added and this, in fading, leaves pigmentation. Tel- 
angiectases are produced in a number of ways, as the following 
table will show. 

I. Embryonic anomalies. Vascular nevi (Chapter XXXII). 
II. Congenital and Familial Predisposition. 

1. Onset of xeroderma pigmentosum (Chapter XXVIII). 

III. Kegressive Changes. Senile Skin (Chapter XVII). 

Minute deep red lesions seen in adults, especially the 
aged; possibly nevi, the elements of which were congeni- 
tally present, the development of which was late. Both 
of these conditions might well be due to a degeneration of 
the elastic tissue either within or without the vessels, caus- 
ing the vascular walls to relax, thus leading to dilatation. 

IV. Inflammatory Changes in the Skin. 

1. Unknown or undetermined origin 

a. Seborrhoea causing telangiectases of the face. 
83 



84 DERMATOLOGY 

b. Rosacea acting similarly. 

c. Morphoea, Scleroderma. 

2. Known or presumably specific causes 

a. Acne telangiectatic^ (tuberculosis?). 

b. Angiokeratoma, (tuberculosis?). 

c. Lupus Erythematosus (tuberculosis?). 

d. Lupus Pernio (tuberculosis). 

e. Pernio. 

f. Associated with Syphilis. 
V. Physical Causes 

1. Mechanical Causes: Incomplete obstruction to return 

circulation, as for example cirrhosis of the liver; 
pressure of mediastinal, abdominal and pelvic 
masses; venous thrombosis, in the areas tributary to 
the large obstructed trunks capillary dilatation occurs 
in the skin. In the lower extremities even without 
such causes, the position of the limbs frequently de- 
termines the presence of telangiestases seen particu- 
larly on the thigh. Gravidity also predisposes to 
dilatation of the skin vessels. 

2. Actinic Rays: X-Rays, radium, exposure to sunlight 

(sailors and agriculturists, etc.). 

3. Heat: Burns and Scars resulting therefrom. 

4. Cold: Frost-bite (see Pernio). 

VI. Chemical Agents: Acids, Alkalies, Caustics, etc. 
VII. Digestive disturbances. Nasal and facial telangiectases 
from gastritis, the excessive use of alcohol, condiments, 
rich sauces. Sustained icterus also at times is respon- 
sible. 
VIII. Chronic valvular disease, congenital or acquired; 1 chronic 
pulmonary disease. These might also be grouped among 
the mechanical causes. 
IX. Metabolic and ductless gland diseases; vasomotor disturb- 
ances ; malar flush of myxoedema ; exaggeration of rosacea 
and lupus erythematosus at climacteric. 
X. Essential Telangiectasia 

1. Purpura annularis telangiectoides. 

2. A peculiar progressive pigmentary disease of the skin. 

3. Angiokeratoma. 

4. Angioma serpiginosum. 



DISEASES OF THE CUTANEOUS VESSELS 85 

It is the last group with which, in the main, this chapter deals. 
When diseases are characterized by the meaningless word " essen- 
tial," it is for the sole reason that we are ignorant of their nature. 
It would be both more honest and more exact to classify them as 
maladies of undertermined origin. An apparently clear clinical 
entity from among this group may be the result of any one of numer- 
ous pathogenic forces, and conversely, the same pathogenic forces 
may provoke different clinical pictures. This all depends upon the 
phenomenon of cutaneous reactions. Thus, angioma serpiginosum 
and purpura telangiectatica, in general accounted distinct clinical 
entities, may in effect not be so, an impression that cannot be 
escaped after reading Stokes's and Wise's respective papers on 
syphilitic telangiectasa and angioma serpiginosum, although it is 
improbable that these authors intentionally conveyed such an 
idea. This is not stated to confuse the student, but to prevent the 
misconception that certain conditions, assumed to be clinically dis- 
tinct, necessarily are. Before describing these diseases, it will 
be necessary to devote a few paragraphs to telangiectasis as a whole. 

Telangiectases may be minute, barely perceptible, bright red 
dots, corresponding to dilated capillaries in the papillae. These 
look like grains of red pepper studded over the skin and are com- 
monly found in angioma serpiginosum, purpura telangiectatica, and 
Stokes described them in his case due to syphilis. They may also 
occur in any other telangiectatic disease of any nature whatever, for 
they simply represent the minutest possible vascular dilatation clin- 
ically recognizable, and nothing more. In slightly larger areas of 
vascular disturbances when capillaries in from four to twenty 
papillae are involved, a tiny crimson or claret colored macule is 
formed, or if the blood is venous a purplish shade is present. Such 
lesions may be nevi, or that type of possible nevi which develop 
in later years over the trunk. These two varieties are situated in 
the capillary loops. 

When the process involves the longitudinal vessels in the various 
depths of the cutis the clinical manifestations thereof are delicately 
curved, or tortuous lines varying in color from brilliant crimson to 
purplish, according to whether the vessel is an artery or vein. 
Grouping of these vessels may lead to a curious lacy design. Such 
telangiectases are found in the diseases to be discussed, as well as 
in nevi, or as the result of inflammation (rosacea, lupus erythe- 
matosus, etc.), or from obstruction to return circulation (cirrhosis, 
cardiac, pulmonary disease, etc.). Often this and the punctate 



86 DEEMATOLOGY 

type are seen together. 'Not infrequently, also, an anatomical asso- 
ciation of the two exists with the punctate element in the centre and 
the longitudinal lesions radiating thence in a spider-like manner. 
This forms the so-called nevus araneus. At times the centre is 
slightly raised. These are rarely true nevi. They usually occur 
on the cheek, but often elsewhere, and occasionally may be due to 
trauma such as the sting of an insect. Finally, in a more or less 
restricted area all of the smaller vessels may be involved. This 
imparts a general redness to the affected locality, the color of which 
will be determined by the amount of arterial or venous blood present. 
A red macule is engendered which appears to be of an even tone 
until minutely examined, whereupon the component elements may 
be clearly discerned. At times in the midst of such a surface other 
telangiectasia may be seen. 

Pathologically, these lesions are the result of congenital vascular 
malformation or relaxation of the vessel walls, hypertrophy of the 
vessels, or hyperplasia due to any cause whatever, chiefly though to 
some type of inflammation. A diseased vessel is capable of rupture, 
or it may otherwise become permeable, so that in connection with 
some forms of telangiectasis, as in purpura annularis, and Scham- 
berg's pigmentary disease, pigmentation arises secondary to macro- 
scopic or microscopic blood extravasation. Furthermore, epider- 
mal changes, edema, atrophy and desquamation are possible. 

PURPURA ANNULARIS TELANGIECTOIDES 

Synonym. Telangiectasia Follicularis Annulata. (Majocchi, 
1896.) 

Definition. This disease is a rare vascular disturbance charac- 
terized by the presence of telangiectasia, purpura, pigmentation 
and atrophy, usually remaining confined to the lower limbs, but at 
times becoming universal. 

Symptoms. The early lesions arise below the knees as small 
red puncta about the follicles. These enlarge gradually by means 
of an excentric growth. The eruption is symmetrical and, as the 
rings enlarge, they heal centrally. A slight superficial atrophy 
sometimes remains, as do pigmentations caused by minute hemor- 
rhages. The aspect of a fully developed case is an admixture of 
telangiectatic spots about the follicles, annular telangiectatic macules, 
or macules formed by segments of circles, areas of purpura, pigmen- 
tation and atrophy. No subjective symptoms are present and a fine 
desquamation at times exists. 



DISEASES OF THE CUTANEOUS VESSELS 87 

Course. The disease begins insidiously, runs a chronic course 
extending over a period of months, may become stationary at any 
point and remain so for a long period. In any case it gradually 
disappears. 

Varieties. But one variety is known, although Cramer described 
a case with necrosis and deformity. Landsteiner mentions a variety 
that is not annular. 

Differential Diagnosis. Angioma serpiginosum, parapsoriasis 
and cutis marmorata must be ruled out. The first will be dealt with 
below.! Parapsoriasis is a papular and patchy, scaling disease with- 
out marked telangiectases. It runs a chronic course and resembles 
psoriasis. Cutis marmorata is a universal transitory manifesta- 
tion, characterized by a tracery of congested veins forming lacy bands 
among which are scattered islands or normal skin. 

Etiology and Pathogenesis. Young adult males are more fre- 
quently attacked than females. Auto-intoxication, tuberculosis, 
nervousness, trophic disturbances and familial predisposition are 
among the alleged causes. Brandweiner obtained a positive tuber- 
culin reaction in one case. Actually, nothing is known of the causa- 
tion of the disease. 

Treatment. There is no rational therapy for the ailment. 

Prognosis. The prognosis is invariably good. If left to itself 
the disease gradually disappears. Even in the rare necrotic forms 
the lesions disappear leaving harmless scars. 

A PECULIAR PROGRESSIVE! PIGMENTARY DISEASE OF THE SKIN" 

(Schamberg's Disease) 

This malady starts gradually on the shins and involves the ankles, knees 
and dorsum of the feet. It is characterized by sharply defined reddish 
brown lesions, varying in size, and beyond the borders of which are brown- 
ish macules and tiny puncta resembling granules of Cayenne pepper. In 
involuting, the lesions leave a slightly diffuse brownish or yellowish stain. 

ANGIOKERATOMA 

This curious and somewhat rare condition is named after Mibelli who 
described it in 1889. It consists of small, roughened papular or warty 
lesions on the backs of the fingers and toes of young individuals. These 
raised lesions surmount telangiectases. They usually appear after an at- 
tack of chillblains and in delicate individuals. Although their relation to 
tuberculosis is not definitely proved, it is widely assumed. Bore reported 
a case associated with erythema indnratum (Bazin) and the condition is 
classed among the tuberculides. It is not a serious disease and the therapy 
consists of tonics, measures directed toward curing a possible tuberculosis, 



88 DERMATOLOGY 

and the removal of the lesions with caustics or by electrolysis. The prog- 
nosis as to the skin condition is good. Stumpke described a diffuse variety 
in a man of twenty-eight. This is extremely unusual, although Fabry had 
already mentioned such cases. The condition is also at times found on the 
scrotum, persisting indefinitely, the patient remaining healthy, and cer- 
tainly creating no impression of tuberculosis. 

ANGIOMA SERPIGINOSTJM 

Synonyms. Infective Angioma; Nevus Lupus; A Peculiar 
Form of Serpiginous and Infective Nevoid Disease (Hutchinson). 

Definition. Angioma Serpiginosum is a chronic inflammation of 
the smaller cutaneous vessels resulting in their dilatation, hypertro- 
phy and hyperplasia, at times associated with superficial atrophy of 
the affected integument. According to Wise, but twenty-five cases 
have been noted in the literature. Since the publication of this 
paper, however, a few more instances have been reported. 

Symptoms. Any portion of the body may be the starting point 
of the malady, which usually begins either with diffuse red macules, 
or cayenne pepper-like spots. These arrange themselves in groups 
which are symmetrically distributed and spread serpiginously. As 
the eruption extends, it assumes a varied configuration and is com- 
posed of several elements as follows: (1) Minute puncta resembling 
grains of red pepper and not very numerous; (2) Areas of diffuse 
uniform redness varying in shade and tone, and somewhat suggest- 
ing the congested patches caused by cold; (3) Vascular papules from 
the size of a pinhead to a lentil, scattered about proximally and re- 
sembling small angiomata which cannot be rendered entirely pale 
upon pressure; (4) Delicate vascular rings which are universal, 
symmetrical and the most abundant type of lesion. These rings are 
pink or red, not sharply circumscribed, some having depressed cen- 
tres. They are from 1% mm. to 2 cm. in diameter. (5) Mesh- 
works of irregularly curved and crooked lines, telangiectatic in char- 
acter; (6) Pigmented lesions, chiefly on the legs, yellowish or brown- 
ish in shade; (7) spots, on the neck or trunk, which are round or 
ovoid, white, glistening and slightly depressed. 

There are no noteworthy subjective symptoms. A universal 
brawny desquamation sometimes is present. The composite picture 
is a very startling one since the various elements described exist side 
by side in no regular order. 

Course. The onset is insidious, the progress gradual, covering 
a period of years until, at times, the entire body is involved. Fre- 
quently, however, the affected areas remain restricted. Given lesions 



DISEASES OF THE CUTANEOUS VESSELS 89 

may disappear leaving no trace, or a slight superficial loss of sub- 
stance simulating macular atrophy. 

Varieties. The varieties depend upon the predominance of one 
type of the many component lesions and the extensiveness of the 
involvement, but the disease cannot be grouped into definite clinical 
subdivisions, as for instance lichen or psoriasis may be. 

Differential Diagnosis. Angioma serpiginosum differs from 
purpura annularis mainly because it lacks purpura; from angioker- 
atoma because of its localization and lack of warty growths; from 
Schamberg's Disease because the latter is confined to the lower ex- 
tremities, and lacks the variety of the lesions present in the former. 
Cutis marmorata has already been described and may easily be 
ruled out. Parapsoriasis, secondary syphilis and macular atrophy, 
all of which may slightly simulate the serpiginous angioma, cannot 
be seriously confused with it because of their definite clinical attri- 
butes and lack of telangiectases. 

Etiology and Pathogenesis. This is entirely unknown. At 
times the eruption appears to start from a vascular nevus ; far more 
frequently it arises apparently spontaneously. Race, age, sex and 
general health bear no relation to the disease. In four instances, 
according to Wise, the condition was found to exist at birth. 

Treatment. There is no rational therapy. Wise improved his 
case by the use of the Kromayer lamp. 

Prognosis. As regards life and general health the prognosis 
is good. The disease usually remains limited, often becomes gener- 
alized, and rarely involutes completely. Thus, the prospects of a 
cure are slight. 

To dismiss the subject of " essential " telangiectases at this point 
were but half to discuss the matter. There is no possibility of con- 
fusing angiokeratoma of Mibelli with the other three, and there is 
a strong presumption that it may be related to tuberculosis. The 
remainder of the group, however, have many points in common so 
that to question the logic of too sharply differentiating them would 
not be entirely unreasonable. The Cayenne pepper spots, small 
papular telangiectases, telangiectatic blotches, pigmentation and des- 
quamation are common to all. Purpura annularis is distinguished 
by a definite purpura, but the presence of pigmentation in the other 
two is very probably due to blood extravasation not clinically rec- 
ognizable. Atrophy occurs in purpura annularis and angioma ser- 
piginosum. Schamberg's disease is confined to the legs, while pur- 



90 DERMATOLOGY 

pura annularis usually involves the thighs and legs, although it may 
involve the arms. Angioma serpiginosum stands alone in the ex- 
ten si veness of its distribution, and purpura annularis in the fact 
that the process starts about the follicles and that local necrosis 
may develop. On the other hand, there is a certain generic likeness 
between necrosis and atrophy. Thus, with the exception of the fol- 
licular involvement of purpura annularis, there is not a single 
feature of those enumerated that is not found in at least two, if 
not three, of the diseases. This makes it difficult to believe in them 
as definite entities. 

Stokes intimated this in his paper on telangiectasia in syphilis. 
In the case he reported, a large number of lesions simulated the 
types observed in the " essential " telangiectasia. A histological 
study showed an inflammation of the cutaneous capillaries with in- 
filtrations about them. The microscopic anatomy of angioma ser- 
piginosum, purpura annularis and Schamberg's disease bears close 
similarity to that of Stokes's case. In discussing the general 
etiology of this group, Stokes was able to illustrate in how many 
instances a probable cause exists. This proves that the telangiec- 
tasia are really reactions to numerous causes, and that if ever they 
are to be understood, it will be necessary to attack the problem from 
the standpoint of causation rather than to be satisfied with the 
isolation and denomination of clinical entities, which after all may 
possibly not be entities. 

The Gangrenes are given a place in this chapter because their un- 
derlying canses are roughly similar to those of telangiectasia. The 
main difference between the two groups is in the size of the vessels 
involved. Because those which play a part in the gangrenes are 
more important, the destruction of tissue is greater, but it must 
not be forgotten that telangiectases lead to atrophy and purpura 
annularis may lead to necrosis. Thus telangiectatic diseases and the 
gangrenes represent differences in degree, but are evidently not gen- 
erically far apart, at least, so far as the question of vascular path- 
ology is concerned. The causes of gangrene are : 

I. Nervous Diseases 
1. Central 

a. Tabes dorsalis, syringomyelia, Morvan's disease, 

causing perforating ulcers. 

b. Gangrenous zoster. 



DISEASES OF THE CUTANEOUS VESSELS 91 

2. Peripheral — Probably none. This question has not yet 

been cleared up. Lepra may be in this group. 

3. Psychic — Hysterical mutilations. 

II. Metabolic Disturbances and Diseases of the Vessels 

1. Diabetic gangrene, due either to the direct effect of toxins 

on the vessels or on the vascular nerves (trophoneu- 
roses). 

2. Thromboangitis obliterans. 

3. Raynaud's disease (Symmetrical gangrene). 
4.) Ergotism. 

III. Cachectic 

1. Dermatitis gangrenosa infantum. 

2. Decubitus (bedsores). Typhoid fever, cachexias such as 

tuberculosis, carcinomatosis, etc. 
IV. Physical Causes — Burns, frostbite, ligation of vessels. 
V. Infections — Noma, nosocomial gangrene, gas bacillus gan- 
grene, erosive gangrenous balanitis, syphilis, tuberculous 
lepra. 
VI. Unclassified groups of Gangrene Arising in Other Diseases. 
Hydroa vacciniforme (Chapter IX) ; Gangrenous syphilis 
(Chapter XL) ; Granuloma necroticum, lepra, tubercu- 
losis (Chapter XXV). 

The divisions in this table are more or less arbitrary. Three 
factors appear to be important in the productions of gangrene; a 
diminution of resistance in the tissues, a vascular disturbance, and 
finally, perhaps a neurotrophic disturbance which may be central or 
in the vessel nerves. 

I. Local Disturbances Favoring Necrosis 

1. Physical 

a. Thermal changes — freezing, burning. 

b. Pressure — Decubitus. 

2. Infection — Dermatitis gangrenosa infantum, noma, etc., 

(see V above, table). 

3. Chemicals and other external agents in vocations; (Hys- 

terical mutilations). 
II. Vascular Disturbances (see II above, table). 

1. Vascular disease, ligation of vessels. 

2. Also chemicals as ergot, or sugar, acetone, diacetic, Beta- 

oxybutyric acid (diabetes) affecting the vessels. 

3. Raynaud's disease. 



92 DERMATOLOGY 

III. Neurotrophic (see I above, table). 

Probably through effect on vessels. (In hysterical mutila- 
tions, the morbid mentality impels use of caustics, etc., to 
produce the lesions). 

Exactly what the interrelationship of these various factors may 
be is not definitely known. Vascular changes alone, such as obliter- 
ating inflammations, thrombosis, embolism, etc., may cause necrosis, 
but there must be a still remoter reason for these disturbances such 
as metabolic disease, injury and central nervous lesions. Patho- 
genic organisms require fertilized soil to become active, and thus 
they again may depend upon biochemical or local disturbances. 
The complexity of the problem might be further illustrated, but it 
must by now be obvious that in cutaneous gangrene, a group of der- 
matoses is presented which etiologically is most unclear, and in 
order to understand which no superficial excursion within the do- 
main of general medicine will suffice. The most important of these 
diseases are diabetic gangrene, Raynaud's disease, dermatitis gan- 
grenosa infantum, decubitus and noma. 

DIABETIC GANGRENE 

This starts in various ways and the commonest forms are seen on 
the sole, or involving the entire lower extremity, beginning some- 
where about the foot. The condition may arise as an indurated, 
hard discoloration, a bleb, or with cutaneous hemorrhages. Necro- 
sis attended with great pain develops. Less common forms are 
zosters leading to gangrene, or the onset occurs with a furuncle or 
carbuncle. Any portion of the skin may be the site of these 
changes. The diagnosis rests upon discovering the presence of 
diabetes. Exactly what the relationship of the disturbed sugar me- 
tabolism is to the necrosis has not yet been explained. Whether it 
is the excess of sugar itself, the acetone, diacetic or Beta-oxybutyric 
acid acting directly upon the tissues or the vessels, or indirectly 
through the central nervous system by means of the vascular nerves, 
is not clear. In the last analysis the disease is vascular. The 
treatment in the first place is that of the diabetes. The glycosuria 
must be controlled by proper diet, and when the urine is free from 
sugar the blood must be examined to determine a possible hyper- 
glycemia. Acidosis must be overcome. The local treatment con- 
sists of antiseptic wet dressings, followed by suitable keratoplasties, 
such as Lassar's paste or diachylon ointment. Amputation of the 



DISEASES OF THE CUTANEOUS VESSELS 93 

affected member may be necessary, but surgery is not to be under- 
taken lightly in this condition, and only when all hope of benefit 
by expectant treatment is gone. On the other hand, surgery should 
not be delayed until the patient is moribund. The prognosis is 
always grave, but with proper treatment and comparatively slight 
involvement many cases get well. Recurrences are common, how- 
ever, and greatly to be dreaded. 

Raynaud's disease 

Synonyms. Symmetrical Gangrene of the Extremities; Local 
Asphyxia. 

Definition. Symmetrical Gangrene is a vascular disease, usually 
of the fingers and toes which, after causing local asphyxia, often 
leads to necrosis. 

Symptoms. After exposure to cold, or even, in delicate indi- 
viduals, only in cool weather, pain develops in one or more of the 
fingers or toes, which become white and then red. As the redness 
develops the pain increases in intensity, the affected areas swell, 
grow livid, and finally, either recover or become gangrenous. Gan- 
grene may start as such, or after the formation of a bleb, and the 
involved tissue becomes crusted or mummified. This process in 
turn may end in recovery. Although large portions of tissue may 
be affected, frequently only numerous minute ones are. The local 
temperature is low. It is rare for any other part of the body but 
the extremities to become involved. Fordyce reported a case af- 
fecting the ears. Others have observed the disease on the nose, and 
in a patient of Stevenson s spontaneous amputation of the phalanges 
occurred. All of the nails have been known to fall off simulta- 
neously and suddenly. These manifestations, however, are unusual. 
Ormsby has noted telangiectasia of the face and arms, and calcareous 
deposits over the extensor surfaces of the fingers and elbows. 

Course. The disease follows exposure. After several paroxys- 
mal attacks of local syncopy and asphyxia, gangrene may or may 
not set in. As a rule even the latter is capable of improvement. 
Usually years elapse before the period of breaking down arrives. 

Differential Diagnosis. Frostbite, the first stage of sclero- 
derma, erythromelalgia and lupus erythematosus are the four diseases, 
most closely simulating symmetrical gangrene. Frostbite rarely 
leads to necrosis unless the exposure has been prolonged, or the tem- 
perature unusually low. The absence of paroxysmal attacks, and 
freedom from symptoms in warm weather favor the diagnosis of 



94 DERMATOLOGY 

frostbite; if Raynaud's disease, it persists throughout the year, 
although it is modified in warm weather. Often it is impossible 
to distinguish these two illnesses except after years of observation. 
Scleroderma of the hands or feet does not lead to necrosis until the 
atrophic stage has been reached, and here the gangrene is not due 
primarily to the vascular disease, but to a stretching of the atten- 
uated skin over bony prominences. Erythromelalgia is rosy red, 
rather livid, and at times purple. The color is intensified when 
the affected parts are dependent and becomes normal when they 
are elevated. ~No gangrene develops, although there may be atrophy, 
and there is hyperthermalgesia to both heat and cold. Lupus ery- 
thematosus can be confused with Raynaud's disease only when the 
nose, ears and cheeks are affected. The scaling of lupus and the 
atrophy establish the diagnosis of this disease. 

Etiology and Pathogenesis. The etiology of symmetrical gan- 
grene is not understood. It has been known to follow any serious 
illness and Lustgarten and Klotz thought that syphilis of the vessels 
was the cause. 

Treatment. The therapy is purely expectant. Anodynes to re- 
lieve the pain, wet dressings, and alternately plunging the affected 
parts in hot and cold water are of benefit. In the eventuality of 
extensive gangrene, amputation may become necessary. When gan- 
grenous areas appear, antiseptic dressings, etc., are indicated. 

Prognosis. Although at times the outlook as regards life is 
serious, this is usually not the case. As a rule, when the involve- 
ment is slight the patient recovers from the individual attacks. The 
disease itself, however, is incurable. 

DERMATITIS GANGRENOSA INFANTUM 

Synonyms. Multiple Disseminated Gangrene of the Skin; 
Varicella Gangrenosa; Pemphigus Gangrenosus; Rupia Escharot- 
ica ; Ecthyma Terebrans Infantum ; Impetigo Cachectica ; Ecthyma 
Cachecticum; Ecthyma Gangrenosum. 

Definition. This disease, although not rare, is infrequent. It 
is a multiple disseminated cutaneous gangrene seen in cachectic in- 
dividuals and probably caused by the bacillus pyocyaneus. 

Symptoms. The disease begins in children, rarely older than 
two years, usually as the sequel to a serious acute illness, or in connec- 
tion with marasmus. The glutei are the commonest site affected, 
although no area of the body is necessarily immune, and the earliest 
lesions are erythemas, nodules, pustules or blebs which rapidly 



DISEASES OF THE CUTANEOUS VESSELS 95 

break down and become crusted. Removal of the crust uncovers 
a sharply circumscribed punched out ulcer surrounded by a red 
areola of variable width. In the course of time healing takes place 
and depressed scars remain. The lesions may be closely grouped 
together or sparse, and at times general symptoms — vomiting, diar- 
rhoea and variably high fever — enter into the picture. 

Course. The course of the malady is determined by the ease 
with which the general condition of the patient may be improved. 

Differential Diagnosis. During small pox and varicella epi- 
demics, these diseases must be ruled out. The localization of der- 
matitis gangrenosa infantum to the glutei, and the characteristics of 
the two exanthemata mentioned will serve as fairly reliable guides 
to prevent errors in diagnosis. Pemphigus, too, may occasionally 
cause confusion, but there again the restricted localization of the 
other disease, and the fact that pemphigus rarely causes necrosis, 
will suffice to allay doubt. A much more difficult disease to exclude 
is congenital syphilis. Syphilis, in infants, is commonly found upon 
the buttocks, although of course the lesions are not necessarily con- 
fined there. The Wassermann test and the general features of the 
disease (see Chapter XL) establish the diagnosis. 

Etiology and Pathogenesis. Two factors determine the produc- 
tion of the disease; a preceding serious illness or cachexia, and the 
activity of the pyocyaneus bacillus. This organism is always 
found in the superficial portion of the lesions, but has never been 
demonstrated in the thrombosed capillaries prominent in the micro- 
scopic anatomy. Although infants are usually affected, adults may 
be. 

Treatment. Two factors are here to be considered — the general 
and the local. The former involves proper feeding and other meas- 
ures commonly employed to strengthen feeble infants. Locally, wet 
dressings of aluminium acetate to cleanse the ulcers, followed by 
the applications of ammoniated mercury ointment, will almost al- 
ways effect a cure. 

Prognosis. This is good as a rule. At times, however, death 
ensues, but it is doubtful whether this results so much from the local 
as the underlying condition. 

DECUBITUS 

Decubitis or Bedsore develops at points of pressure in individuals 
long confined to bed by protracted acute, or wasting illnesses. 
Thus, in typhoid fever, in the final stages of carcinomatosis, tuber- 



96 DEKMATOLOGY 

culosis, tabes dorsalis and the like, this condition is found. Its 
favorite site is over the sacrum, although it often appears at any 
point of prolonged pressure. At first, as a rule, an erythema arises, 
accompanied by edema, a bleb or blebs, after which necrosis sets 
in, and this, increasing, forms an ulcer with red, irregular, swollen, 
undermined borders. A tendency to peripheral extension is mani- 
fested, and the necrotic area may become truly huge, attaining a 
diameter of from four to ten inches. There is considerable local 
pain. In typhoid fever the prognosis of the decubitus is good. In 
the cachexias, because no relief for the underlying illness is possi- 
ble, the ulcers are practically incurable. 

Treatment of the condition is prophylactic and actual. Prophy- 
laxis lies chiefly in the domain of nursing. A bed-ridden patient 
should be sponged, rubbed with alcohol and liberally powdered 
daily; the bed sheets should be properly stretched and a daily in- 
spection should be made by the physician to apprise himself of the 
first sign of decubitus. Should there be only the faintest suspicion 
of its onset, the affected region must be gently massaged with alcohol 
and powdered twice a day, a bed-ring given the patient, so adjusted 
as to relieve the pressure over the erythema, and the position of the 
patient changed from time to time. This will serve to prevent the 
necrosis. After necrosis has once begun, the ulcer must be cleansed 
daily with hydrogen peroxide, a light dressing of Lassars paste 
applied, and the patient should be placed on a bed-ring. Under these 
conditions nearly all typhoid decubiti are curable. Such is not the 
case, however, with those arising at the end stages of the cachexias 
and central nervous diseases. Here, the most that may be accom- 
plished is to keep the lesions clean and in a measure limit their in- 
definite advance. 

XO^IA 

Synonyms. Gangrenous Stomatitis. 

Definition. Xoma is a gangrene of the mucous membranes, chiefly 
buccal, usually arising in weak, institutional children after one of the 
acute infectious diseases, measles being the most frequent precursor. 

Symptoms. The disease begins with blebs in the mouth which rapidly 
extend and become gangrenous, the temperature often rising as high as 
105°. The alveolar process, cheeks and lips may become involved, and at 
times a large part of the face is included in the necrosis. 

Varieties. Occasionally the vulva is the site of noma. 

Etiology and Pathogenesis. The disease is clearly epidemic and arises 
after acute infectious diseases in children's hospitals, the contagion prob- 
ably being conveyed by means of lax nursing methods. 

Treatment. Prophylaxis in the form of individual utensils and appli- 



DISEASES OF THE CUTANEOUS VESSELS 97 

ances and towels for the patients, asepsis on the part of attendants and 
physicians, and daily cleansing of the mouth, are the best means of avoiding 
noma. When it once appears, aseptic washes should be employed. At 
times surgery is necessary. 

Prognosis. Three-fourths of those affected die. 

The gangrenes seen in central nervous diseases, barring decubitus, need 
not be mentioned here, but in any gangrene without an easily explicable 
cause, maladies of the cerebrospinal axis should be borne in mind. 

Hysterical Mutilations are scarcely true gangrenes, since they are usually 
due to the local application of a caustic, or to some physical trauma. (See 
Chapter IX.) Ergotism is now so rare that a description of the disease 
may be dispensed with. Gangrenes of physical origin, save frostbite, are 
scarcely true gangrenes since they are temporary and end with the removal 
of the causes. Neither are they due to primary vascular disease, but to 
local tissue destruction. Frostbite will be described in Chapter IX. 
Nosocomial gangrene and Erosive balanitis are bacterial infections. (See 
Chapter XXIII.) The remainder of this group (Division VI of the first 
table) will be described in suitable chapters. 



GROUP II. CUTANEOUS REACTIONS CHARACTERIZED 
BY SEROUS EXUDATION 

The diseases of this group possess the common feature of having 
vesicles or bullae as their essential lesion. Etiologically, they are 
by no means closely allied. In fact in eczema, which is actually 
only dermatitis, the causes are innumerable. Intertrigo is largely 
a mechanical dermatosis; the nature of dermatitis repens and pom- 
pholyx is not entirely clear; while herpes and zoster are fairly 
definitely localized diseases of the central nervous system, or at the 
very least, nerve ganglia, whatever their exciting cause may be. 
In their course, distribution and in the grouping of the lesions, these 
conditions are distinct one from the other. Occasionally, admixed 
with vesicles, may be found bullae. 

CHAPTER IX 

VESICULAR DISEASES 

HERPES (FIG. 9) 

Synonyms. Herpes Simplex; Eever Blister; Cold Sore; Erench 
Dartre ; German, Blaschenflechte. 

Definition. Herpes is an acute eruption of a group of vesicles 
usually situated at a mucocutaneous junction. 

Symptoms. With a slight sensation of tension, pain or heat, 
lasting from a few hours to a day, or without any prodromata, there 
is an outbreak of a few grouped vesicles (Fig. 9) on a slightly swollen 
erythematous base. The symptoms mentioned may persist after the 
appearance of the eruption, and slight fever may accompany the 
attack. The vesicles are tiny at first, tense, glistening and yellowish, 
from two or three to a dozen in number, and filled with limpid fluid 
which may become red in case there is hemorrhage, or a muddy 
yellow if secondary infection takes place. After a few days the 
vesicles become flaccid, and dry into a crust, or they rupture. In 
the latter event a crust also forms, the color of which is that of 
honey, brownish or dirty according to the nature of the contents. 
Some days later the crust falls off leaving a pinkish epithelialized 

98 



VESICULAE DISEASES 99 

surface below, which soon returns to its normal color. Attacks may 
occur anywhere in the mouth or even, it is said, on the larynx. The 
buccal lesions resemble aphthae. 

Course. As a rule the course of the individual attack is short, 
rarely lasting for more than ten days. Often herpes is a symptom 
of an acute infectious disease. This form corresponds to the first 
in evolution and disappearance. Very commonly there are re- 
current varieties, each attack conforming to the outline just given. 
These recurrences may extend over years, coming on at intervals or 
succeeding one another so rapidly that the patient is never without 
some marks of the disease. At times outbreaks regularly accompany 
menstruation. 

Varieties. Herpes may be primary, symptomatic, or chronic, 
as already indicated. In addition varieties according to site, each 
with a Latin name, are described. Thus, there are herpes labialis, 
herpes nasae, linguae, palpebrarum, preputials, clitoridis and so 
on infinitely. This is as absurd as would be regarding pneumonia of 
the upper or lower lobe, right or left lung, as separate clinical enti- 
ties. A rare condition known as generalized herpes has been 
described. 

Differential Diagnosis. Herpes resembles no other condition 
strongly. At times, when the lesions appear on the genitalia, it 
may not be simple to rule out a syphilitic primary lesion, particularly 
since specific infection may take place in the ruptured vesicle. 
Ordinarily, herpes is not indurated (although on the penis any 
lesion may become so) and the spirochaetae are absent. At times, 
labial and facial (Fig. 9) herpes when infected, simulate impetigo 
contagiosa. In the latter, however, the lesions are disseminated, 
whereas herpes is confined to one area. On the body, single small 
patches of vesicular dermatitis may suggest herpes, but here again the 
fact that herpes remains restricted while the other malady is dis- 
seminated, should prevent confusion. 

Etiology and Pathogenesis. Herpes is not due to an isolated 
cause. It appears either spontaneously at the onset of acute infec- 
tious diseases, or may be caused by arsenic (see Chapter VII). 
When it appears spontaneously it is an index of some internal dis- 
turbance, possibly digestive or metabolic. This, however, is still 
speculative. The symptomatic forms are encountered at the onset 
of pneumonia, grippe, colds, scarlatina, associated with cerebro- 
spinal meningitis, malaria, and diphtheria. It is so rarely present 
in typhoid fever as almost to serve to exclude this disease. Attacks 



100 DERMATOLOGY 

may be induced in the predisposed by slight friction. Herpes pro- 
genitalis is common after any form of erotic stimulation, chiefly 
however after illicit coitus especially in syphilophobics. It not in- 
frequently occurs, nevertheless, without any apparent psychic or 
physical cause. 

Treatment. It is common in those subject to herpes to be aware 
of an approaching attack through a sensation of tension at the site 
commonly affected. Such cases may often be aborted by a one per- 
cent, solution of menthol in alcohol. This is to be dabbed on every 
hour or so and it frequently controls the process and causes its in- 
volution before the vesicles have formed. After they have, however, 
a similar solution or a weak menthol and camphor salve, to lessen 
itching or pain, may be used. If infection takes place, a mild 
ammoniated mercury salve is indicated. In recurrent cases a thor- 
ough study should be made of the patient's digestion, habits, diet 
and general condition. Any faults should be corrected if possible. 
In a patient troubled with chronic constipation, recurrent attacks of 
herpes were prevented by regulating the intestinal function through 
proper diet and the use of mineral oil. This case is cited to illustrate 
by what simple means apparently obstinate conditions may be con- 
trolled. Herpes progenitalis must be treated with mild antiseptic 
dusting powders, as the sensitive genital mucosa will not tolerate well 
the medicaments which may be used safely elsewhere. 

Prognosis. The prognosis is always good. 

zostee (fig. 10) 

Synonyms. Shingles ; Herpes Zoster ; Ignis Sacer ; Zona ; French, 
Zona ; German, Gurtelausschlag ; Giirtelrose. 

Definition. Zoster is an acute disease characterized by pain and 
the sudden eruption of groups of vesicles on an erythematous base. 
The distribution of these groups is unilateral, restricted and along 
the course of a cutaneous nerve. 

Symptoms. Zoster usually begins with severe pain of the type 
popularly described as neuralgic. After three or four days, and 
frequently accompanied by fever, pinkish spots appear in the painful 
area. The color deepens within twenty-four hours, vesicles develop, 
the pain increases, and burning, itching or tingling may arise. At 
times the pain is agonizing and has a shooting character. The tense 
vesicles usually contain clear yellow serum, and are closely set in 
patches which vary from the size of a dime to a silver dollar. Local 



VESICULAR DISEASES 101 

adenopathies are almost constant. Hemorrhage into the vesicles is 
not infrequent, imparting a red, purple or brown color to them, and 
secondary infection converts the contents into pus. As desiccation 
sets in the subjective symptoms diminish. Crusts form as in simple 
herpes and finally drop off, while healing usually ensues without 
scar formation. At times the patches become gangrenous, or there 
is a minute necrosis at the site of each vesicle. Permanently de- 
pressed scars result from this. In about a fortnight the disease has 
usually run its course. The aspect of a case of zoster is striking. 
On one side, and following the distribution of a cutaneous nerve 
from its point of emergence to its termination, are found discrete or 
closely set, red islands surmounted by vesicles which may or may 
not be densely grouped, and which are minute or as large as a lentil. 
Scars remaining correspond in their distribution to that of the orig- 
inal lesions. 

Course. The disease begins with sudden, severe or mild pain, 
or none at all, the last being exceptional. After hours or days the 
typical lesions appear, desiccate in a week or two and leave with or 
without scars. Recurrences are rare. 

Varieties. Aside from the varieties determined by location, and 
so designated, as zoster facialis, nuchae, pectoralis, and so forth, 
there are mild types, severe types, types in which a typical group of 
lesions is accompanied by disseminated varicelliform vesicles and 
systemic symptoms, a gangrenous, a hemorrhagic, and a most unusual 
bilateral form in which nerves at the same or at two different levels 
may be affected, Tryr has described a generalized form. 

It is a strange fact that the lower extremities usually escape the 
disease. Zoster of the upper branch of the trigeminal nerve at 
times causes lesions to appear on the conjunctiva, sclera or cornea. 
This form is accompanied by excruciating pains in the eye, lachrima- 
tion and photophobia. In comparing the facial forms which are 
most intense with those on the lower extremities, Montgomery and 
Culver pointed out that many neuralgias of the lower extremities 
would be accompanied by zoster, but for the length of the nerve (see 
Etiology below) . This type is called by them zoster d'emblee. 

Differential Diagnosis. So far as the cutaneous lesions are con- 
cerned, zoster can be confused with practically nothing else. Before 
the eruption has appeared, however, during the stage of prodromal 
pain, all sorts of conditions may be simulated according to the site 
involved; torticollis, acute pleurisy, cholecystitis, gall-stone colic, 



102 DERMATOLOGY 

appendicitis, renal colic, et cetera. Frequently enough a laparotomy 
has heen performed, the suspected viscus examined and found normal, 
while three days after the operation zoster has appeared. 

Etiology and Pathogenesis. Zoster may be due to trauma, dis- 
eases of peripheral nerves {Bareiisprung' s, Charcot's and Kaposi's 
cases, due to tuberculous changes in the nerves, quoted by Jarisch), 
reflex neuroses, spasm of vessels in dilatation (Kreibich). Haight 
and Kaposi considered the disease infectious and the preponderance 
of evidence favors this view. Bocay reported an endemic of herpes 
in one family. Avdry treated a husband and wife who were affected 
simultaneously. These two experiences raise the question of con- 
tagion. Montgomery and Culver offered the opinion that the infec- 
tion gained access to the body from without, travelled up the nerve 
to the posterior root ganglion causing a hemorrhagic ganglionitis 
which in turn determined the zoster. This theory, fanciful as it 
appears, would account for the fact at least that the longest nerves, 
as those in the lower extremity, rarely are involved in the cutaneous 
manifestations of zoster, although they pain. Head and Campbell 
found changes in the posterior root ganglion of the nerve along the 
distribution of which zoster lesions were found. Rosenow and 
Oftedal produced the disease in animals by injecting streptococci 
from pyorrhoea pockets and tonsils. Hemorrhages were produced 
in the posterior root ganglia with a peringanglionitis. Gram posi- 
tive cocci were found in the nerve lesions. True zoster produces 
immunity to subsequent attacks. 

In addition to this it must be remembered, however, that zoster- 
like eruptions follow the use of certain drugs or poisons, as arsenic 
and atropin; general diseases; both the cachexias and acute and 
chronic infections as carcinomatosis, sepsis, malaria, uremia; and 
injuries or operations such as intraspinous injections, gunshot wounds 
and even vaccination. This by no means exhausts the list. Race, 
age and sex do not affect susceptibility to the illness, but it appears 
as though the aged are more seriously affected than the young. 

Treatment. The local treatment of zoster corresponds to that of 
simple herpes. Often, wet dressings afford great relief, as alum- 
inium acetate, Thiersch's solution and weak bichloride fomentations. 
For excessive local pain sprays of carbolic acid one percent., menthol 
one percent, in alcohol, to which about ten percent, of rose water 
has been added, will be found useful. A five percent, cocaine oint- 
ment, or anesthesin dusted on the open lesions are also of great serv- 
ice. Should the neuralgia be very severe bromides, codein or even 



VESICULAR DISEASES 103 

morphine must be employed. In ocular lesions wet dressings of 
boric acid must be employed and weak dionin solutions may be in- 
stilled into the conjunctival sac, but it is wiser to enlist the services 
of a competent ophthalmologist to control these special indications. 
The salicylates, salol and iodide of potassium have been used in- 
ternally. 

Prognosis. The prognosis in zoster is good. 

Pompholyx, also called cheiropompholyx, is a vesicular disease of the 
hands and feet, prone to be symmetrical and associated with a disturbance 
of the sweat secretion. It favors the dorsum of the hands and fingers, or 
foot and toes, the interdigital spaces, palms and soles, and is more frequent 
on the hands than feet. The vesicles vary in size up to that of a pea, 
contain a clear, alkaline fluid, are at first imbedded in the skin resembling 
sago kernels. Later they become elevated. They rarely rupture spon- 
taneously. Tingling, itching, burning, pain, intumescence and erythema 
complete the picture. Increased sweat secretion is present and the disease 
is most frequent in the neurotic. The treatment consists of tonics and the 
local measures to be described in connection with vesicular dermatitis. 
Roentgen ray therapy is of great service. The disease is common during 
summer and is one of the local predisposing causes of acute dermatitis. 
(See dermatitis below.) Pompholyx is possibly of fungus origin, and not, 
as tradition claims, a dishydrosis. 

Intertrigo is an inflammation of the skin covering two permanently con- 
tiguous surfaces, as for instance, below the breast, or between the thigh and 
genitals. Local heat, moisture and friction predispose to the disease. The 
symptoms are itching, tenderness and a sensation of heat. The lesion is 
a diffuse erythema covered by macerated epidermis and a secretion is 
formed which stains but does not stiffen linen. At the folding line of the 
two adjacent surfaces a superficial fissure often develops and the odor from 
the affected area is obnoxious. Treatment consists in separating the ap- 
posed surfaces with lint, gentle daily washings with soap and warm water, 
dusting powders of zinc oxide, zinc stearate, talcum, burnt magnesia or 
starch, or ointments such as vaseline, or cold cream. Carron oil (equal 
parts of lime water and linseed oil) is an excellent local sedative when 
applied upon lint. 

SIMPLE DERMATITIS AND ECZEMA 

In a half-hearted and wholly illogical way dermatitis and eczema 
have been regarded as two distinct diseases. They are, however, 
identical clinically and microscopically. The chief reason for the 
separation of the two is the fact that in dermatitis a recognized 
excitant exists, not invariably demonstrable in eczema. This is 
as far as anyone may go to-day in divorcing the two, and this is as 
absurd as it would be to call enterocolitis of unknown origin eczema 
of the intestines, reserving the term enterocolitis only for those 



104 DEEMATOLOGY 

inflammations of known causation. Were it not for the weight of 
tradition the abandonment of the term eczema would be sensible, 
but so much has been written under this title that such a step would 
still be impractical. 

Synonyms. Dermatitis; German, Eccem; Ekzem; French, 
Eczema. 

Definition. Dermatitis (Eczema) is a catarrh of the skin pos- 
sessing the pathological characteristics of an exudative inflammation. 
It is characterized clinically by redness, swelling, the presence of 
papules, vesicles, pustules, weeping, crusting and scaling in various 
combinations. In its course it may be acute, subacute, chronic ; and 
its origin depends upon an interplay between various known and 
unknown local and predisposing causes to which the skin lesions are 
reactions. 

Symptoms. The salient subjective symptom of dermatitis 
(eczema) is itching. Burning is also frequent, and rarely either 
tingling or pain are present. In a certain proportion of acute cases 
slight fever may be found. Objectively, the characteristic features 
are the presence of vesicles, papules, or papulovesicular lesions 
arising upon a swollen erythematous surface. The vesicles either 
rupture or dry. In the first event crusts are formed which finally 
fall off and leave a scaling surface; in the second event the scales 
form at once. The desquamation is either fine or coarse and covers 
a reddened or buff-colored surface, the margins of which fade gradu- 
ally into the normal skin. Should the process persist, the involved 
integument turns red, brownish or buff, and feels leathery. Such a 
surface scales and may become the starting point of new vesicles or 
papules. The markings of the skin are exaggerated, causing a cross 
hatching of furrows. This process is known as lichenification, and 
a lichenified area may be intensely pruritic. The vesicles are usu- 
ally small, about the size of a pinhead, but may be as large as a 
lentil, or even a kidney bean, in which case they are actually small 
blebs. They contain clear yellow serum, which may at times become 
bloody, or purulent. When the vesicles rupture and their contents 
flow out the disease is in the weeping stage. At body folds, over 
joints, or where the infiltration is thick, the skin cracks forming 
fissures or rhagades. Either limited areas, more extensive surfaces, 
or practically the entire skin may be involved, or the process may 
persistently be restricted to one particular site, as on the palms, 
soles, scalp, or about the anus. Furthermore, it may remain for a 
prolonged period in any one of its many stages. Thus, a chronic 



VESICULAR DISEASES 105 

thickened patch may persist about the anus, a vesicular patch or 
patches on the back of the hand or forearm, or a squamous patch on 
the palms or soles. 

Course. This varies enormously. A typical case would begin 
with an itching or burning erythema which would rapidly become 
somewhat edematous, then surmounted by papules or vesicles (Fig. 
11), the smaller ones of which would dry, the larger, rupture and 
weep (Fig. 12). Thereupon crusts (Fig. 12) would form and these 
would be succeeded by scales, after which involution and complete 
healing would take place. This series of gradations, however, in so 
classic a sequence is rare, except in acute dermatitis ; and here it 
must be remembered that involution may occur after the erythema 
without vesiculation, and after vesicles have formed without crusting. 
Scaling would occur in either case. On the other hand, involution 
may have begun, and suddenly the entire process will flare up 
afresh on the partly healed surface. 

The process may start as an acute one and become chronic, or may 
start insidiously without immediate characteristics of the acute type. 
In the first eventuality, after prolonged papulation or vesiculation 
thickened squamous (Fig. 13) patches arise; in the second eventu- 
ality, squamous patches develop gradually with apparently no vesi- 
culation, but as a rule associated with papules seen chiefly at 
the periphery of the patches. Either variety is capable of becoming 
vesicular, and a mutation of vesicular, papular and squamous stages 
occurs lasting for years, and leading to chronic thickening of the 
skin, or lichenification. At times, the scales being friable and 
epithelialization imperfect, while the tissues below are edematous, a 
constant seeping of serum washes away the epidermis. This causes 
the chronic weeping forms. In addition to this, one portion of the 
body may exhibit vesicular patches, another squamous, another weep- 
ing, another lichenified in so varied a combination as to baffle descrip- 
tion. 

The acute types last for days, weeks, or months ; the chronic for 
months or years. Acuity or chronicity besides being applied to the 
disease as a whole may be applied to the course of individual patches. 
Thus, in chronic dermatitis, acute patches of vesiculation may arise, 
or there may be an acute outbreak of grouped papules. 

Varieties. The varieties of dermatitis (eczema) may be enum- 
erated from several standpoints and are: 

I. Varieties Determined by Course : 



106 DERMATOLOGY 

1. Acute. 

2. Chronic. 

II. Varieties Determined by Clinical Aspect ; as vesicular, papular, 
weeping, etc. 
III. Varieties Determined by Site ; as palpebral, palmar, plantar. 
IV. Varieties Determined by Causation ; 

1. External Origin; as ivy poisoning, occupational derma- 

titis, et cetera. 

2. Internal Origin ; as diabetic, nephritic, et cetera. 

3. Local Predisposing Causes; as seborrhoeal, ichthyotic, et 

cetera. 
-i. Unknown Causation. (The only group to which the term 
eczema is applicable.) 
V. Varieties Determined by Age ; as infantile, senile. 

I. Varieties Determined by Course: 1 (See Above.) 

II. Varieties Determined by Clinical Aspect : 

Dermatitis Cracquele is rare. It is characterized by the presence of fine, 
large, irregularly polygonal scales on a small, erythematous surface, and is 
both painful and sensitive. Its appearance suggests the design artificially 
wrought into certain Chinese porcelains known as craquele ware. 

Dermatitis Crust osa. (See Dermatitis Madidans.) 

Dermatitis Erythematosa is a common variety which may occur 
anywhere on the body, but favors the exposed parts, notably the face. 
It itches and burns intensely, scales and becomes edematous, and 
gradually leads to thickening of the skin. The color is usually a 
vivid red, but may be either dusky or purple. Traumatism, such 
as scratching, sharp winds or low temperature intensify the process, 
while scratching alone often causes vesiculation and excoriation. 
Crusts form on injured surfaces. The areas involved are fairly 
sharply demarcated. 

Dermatitis Fissa, or Rhagadiformis. Over joints the thickened 
and inflamed skin cracks and fissures are formed. At body orifices, 
chiefly on the lips, and about the anus, a similar process takes place. 
In winter the entire cutaneous surface and exposed parts may be- 
come inflamed and the epidermis split forming a lacework of shallow 
fissures. This is the process known as chapping. 

Dermatitis Impetiginoides or Pustulosa (Fig. 14). Any type of 

l In the older works the word eczema would replace dermatitis, and the 
qualifying terms would have the neuter ending. 



VESICULAR DISEASES 107 

dermatitis, whether acute or chronic, and wherever situated may 
become infected. In some instances, as in the squamous forms, this 
is due to scratching. In acute forms the vesicles are infected by the 
ubiquitous skin staphylococci. Here, pustules are found admixed 
with the vesicular and squamous lesions. It is a form particularly 
common to children and leads to the formation of dirty yellowish 
green or yellowish brown crusts. Pruritis is usually less intense 
than in the squamous or papular types. 

Dermatitis Lichenoides (Fig. 15) is due to cutaneous thickening 
caused by an infiltration indicating sustained dermatitis. It has been 
erroneously confounded with Vidal's lichen chronicus simplex, or 
Broeq's neurodermitis. It is due to diffuse itching of the integument, 
or to close juxtaposition of papules which coalesce into placques. 
The flexor surfaces are favored, but no portion of the body is immune. 
In color these areas vary from buff to purple, are covered with fine, 
adherent scales, and beyond their periphery are discrete papules. It 
is almost impossible to pick up the leathery skin. Chronicity is 
always implied by this process, but the affected sites commonly 
enough become the starting point of fresh attacks of the acute forms. 

Dermatitis Madidans (Fig. 12). Frequently there is a sustained 
flow of serum from ruptured vesicles, or from imperfectly keratin- 
ized, chronic, edematous and red areas of dermatitis. This form is 
dermatitis madidans or rubra. When the discharge crusts the picture 
created is known as dermatitis crustosa. Any part of the body may 
be involved. The periods of crusting and weeping alternate, and the 
discharge stiffens linen. This is supposed to be a characteristic fea- 
ture of the disease, but all dried serum from any sort of lesion may 
do the same thing. No other disease, however, is marked by so 
abundant a serum flow. 

Dermatitis Nummularis is a form in which coin sized groups of vesicles 
on an erythematous swollen base develop. The patches itch, appear sud- 
denly and tend to relapse. The extensor surfaces of the hands, forearms 
and legs are those most frequently involved. 

Dermatitis Papulosa. See Dermatitis Lichenoides. 

Dermatitis Pustulosa. See Dermatitis Impetiginoides (Fig. 14). 

Dermatitis Rhagadiformis. See Dermatitis Fissa. 

Dermatitis Rubra. See Dermatitis Madidans (Fig. 12). 

Dermatitis Sclerosa is a form closely allied to the lichenoid variety and 
favors the legs, ankles, palms and soles. 

Dermatitis Squamosa is a scaling variety of the disease. The scales are 
small, white, fine, and not imbricated as in psoriasis. 

Dermatitis Verrucosa. In persistent forms, particularly on the lower 



108 DERMATOLOGY 

extremities, the affected areas tend to proliferate and assume a warty 
appearance. This is usually observed in the variety associated with varices 
of the leg. 

Dermatitis Vesiculosa (Fig. 11). This is a common variety of the 
disease. On an erythematous surface, imperceptibly fading off into 
normal skin, minute vesicles arise, each containing a drop of serum. 
The entire area is swollen, hot, itching, or painful, and as the vesicles 
rupture, flaky honey-colored crusts form. In involuting, a squamous, 
or chronic weeping stage is reached, or if the vesicles become in- 
fected, impetiginization occurs. The sites favored by vesicular der- 
matitis are the flexors where the integument is thin, or if the excitant 
be an external agent, as rhus, chemicals and the like, the vesicles 
develop upon the area exposed, and thence may spread to other parts 
of the skin. In such cases, too, the vesicles may be so large as to 
be rather small bullae. Vesiculation may arise on a patch of chronic 
dermatitis, as has already been stated. 

III. Varieties Determined by Site. 

To some extent the picture of this disease is modified by the site 
affected. Essentially, its clinical features are uniform, but a der- 
matitis of the scalp differs in aspect from one in the interdigital 
spaces of the feet purely because of peculiar mechanical, physiological, 
and anatomical conditions, as the warmth and moisture in body folds, 
the presence of hair on the scalp, or all three, as in the axilla. 
Structurally, too, the skin is not alike in all areas. On the scalp, 
about the nose, on the chest and between the shoulder blades, there 
are more sebaceous glands than elsewhere. At these sites and in 
most of the body folds, especially in the axillae, and on the palms 
and soles, sweat glands are found in greater number. The epidermis 
of the last two sites is thicker than anywhere else. These variations 
in hair, sebaceous and sweat structures, and • thickness of the epi- 
dermis are responsible for many of the superficial variations in the 
picture. A similar influence is exerted at the mucocutaneous junc- 
tions. With these facts in mind, it will be well to reclassify der- 
matitis (eczema) from the topical viewpoint. 

The Head. On the scalp two stages of the disease are common, 
the vesicular and squamous. The vesicular form is oftenest ob- 
served in infants, the squamous in adults. In infants the vesicles 
readily become infected causing pustules to develop. The secretion 
of the vesicles and pustules dries among the short hairs which become 
matted into the crusts. On removing the latter, denuded integu- 



VESICULAR DISEASES 109 

ment is exposed, the areas so affected varying in size from a lentil 
to a dime. These are not ulcers, but patches devoid of epidermis and 
they give off serum. Interspersed among the crusted and vesicular 
lesions are scaling patches and excoriations. In adults scaling pre- 
dominates, but the other features enumerated are not infrequently 
present. Very often, too, regional lymph glands are enlarged, and 
in children, in whom the condition is commonly associated with 
pediculosis capitis, suppurative, cervical and postauricular adenitis 
develops. 

The Ears may be the site of the vesicular, scaling and lichenified 
stages of the disease. When the process is acute the lobes swell. 
In the external meatus the scaling variety is common. Behind the 
ears, where they join the head, both the scaling and vesicular forms 
are very frequent, and any irritation, such as the wearing of spec- 
tacles which curve about the ears, augments the intensity of the 
process. 

The Eyelids present three types of the malady : the scaling, lich- 
enified and vesiculopustular, all of which itch. The first is asso- 
ciated with a subacute erythema ; the second is due to chronicity and 
renders the lids, particularly the upper, red, thickened and inelastic ; 
the third chiefly attacks the ciliary margin causing folliculitis with 
a seropurulent discharge which produces swelling and agglutination. 
When the lower lid is involved this organ and the adjacent skin, 
because of the looseness of the cellular tissue, become strikingly 
edematous. When both lids are involved they make the patient look 
as if each eye were encased in a red disc of swollen, vesicular or 
scaling skin. In infants and children in whom the process is severe 
the disease has been regarded as connected with scrofula. This, 
however, remains unproved. 

The Nose. In patients with chronic coryza there is sometimes 
a chronic inflammation of the nares. This is usually of the squamous 
and fissured variety. A vesiculopustular form, often reaching as 
low as the upper lip, is encountered in acute coryza. 

The Lips are frequently involved. In acute forms there is puff- 
ing, and the lesions hurt or itch. A subacute form, radiating from 
the lips to the adjacent integument, is associated with the use of 
tooth powders and mouth washes containing wintergreen and pepper- 
mint. These forms itch intensely and are extremely disfiguring. 
Of course, they denote a hypersusceptibility to the essential oils used 
in the lotions and powders, or nearly all of the human race would 
be thus afflicted. A fissured variety is common in winter. This 



110 DERMATOLOGY 

involves the vermilion border and is known as chapping. It belongs 
to the clinical group of dermatitis fissa. 

The Face. In people from thirty to sixty years old, particularly 
in firemen, sailors, agriculturists, in fact in all exposed to extremes 
of wind, weather and temperature, the forehead, temples and cheeks 
become the site of what is called facial (eczema) dermatitis. The 
skin is thickened, a dusky to purplish red, itches, and alternately 
weeps and scales^ When associated with seborrhoea the scales are 
greasy. The patient tends to rub or scratch his face and this pro- 
duces acute exacerbations of the process, as the result of which weep- 
ing and crusting occur. This form is most obstinate. 

The Neck is often involved in an extension of a persistent variety 
of the above. Any type of the process may be present, most fre- 
quently, however, the lichenified and papular. 

The Upper Extremities present all of the varieties mentioned, 
but there are also some which merit special consideration. The 
nummular variety is the first of these, and it favors the dorsum of the 
hands and the extensor aspect of the forearms. (See nummular der- 
matitis (eczema) for a discription of the clinical appearance.) The 
hands are the site of occupational or professional dermatoses of this 
type and the condition may assume several forms. The commonest 
of these is a vesiculosquamous eruption of the back of the hands which 
is recalcitrant to treatment while the causal irritation is sustained. 
Squamous, lichenified and erythematous varieties are also often ob- 
served, or a mixture of these forms. Surgeons, nurses, chemists, 
factory hands, charwomen, painters, printers, candy manufacturers, 
in fact, those engaged in any manual vocation are subject to the 
disease. A vesiculopustular and erythematous form usually due to 
fungus infection is associated with dysidrosis, particularly pom- 
pholyx, and a chronic squamous palmar variety accompanied by 
fissure formation is often encountered. The nail beds may be red- 
dened and swollen, the nails are gray, longitudinally ridged, and 
often brittle, thickened and distorted. The toe nails may suffer 
similar changes. 

The Lower Extremities too have their peculiar forms. The 
nummular variety is rare. Associated with varicosities a peculiar 
dermatitis develops, accompanied by minute cutaneous hemorrhages 
and followed by ulceration with scaling or hypertrophy of the skin. 
This is the common dermatitis (eczema) so often associated with 
ulcus cruris. The hypertrophic form is commonly known as eczema 
verrucosum, and there is a sclerotic variety known as eczema scleroti- 



VESICULAR DISEASES 111 

cum, all of which have already been in part described. At first 
a vesicular, squamous, or erythematous weeping or crusted der- 
matitis appears, which itches or pains intensely and is often ex- 
coriated. Vivid petechiae then develop which, in fading, turn brown 
and leave a pigmentation, ultimately permanent, which successive 
crops of hemorrhagic lesions intensify. Gradually the skin breaks 
down and an ulcer forms, usually on the outer aspect of the lower 
third of the calf, or over the malleoli. The ulcer has rolled, thick- 
ened, undermined margins and a granulating base which secretes a 
seropurulent substance, often very foul in odor. In the hypertrophic 
forms at the sites mentioned in connection with the ulcers, verrucoid 
plaques develop. Surrounding both the warty patches and ulcers, 
papules are often seen. Rarely, the entire leg becomes elephantiastic 
and studded with verrucoid proliferations from the knees to the feet, 
or with inflammatory lymphatic cysts. 

The Soles are the site of a vesiculobullous (Fig. 16) and a squa- 
mous form. This is identical with the form described on the hands, 
caused by fungi. The commonest fungus is the epidermophyton 
inguinale, and the vast majority of cases formerly regarded as dishy- 
drotic in origin are actually infections. Between the toes vesicular, 
erythematous and scaling lesions develop, as well as between the toes 
and the ball of the sole. Maceration causes the thickened epidermis 
to exfoliate in large, caseous, pure white sheets, exposing painful, red, 
denuded areas of skin which sometimes look glazed, and lead to the 
formation of fissures. A similar form occurs in the interJigital 
spaces on the hands, especially in occupational dermatitis. All of the 
forms seen on the feet are intensely pruriginous and sometimes ex- 
quisitely painful. 

Anal dermatitis (eczema) itches extremely, is either lichenified, 
weeping, or rhagadiform in type and often associated with hemor- 
rhoids, -fissures and fistulae. Equally often, however, it is associated 
with constipation or acid stools, particularly in infants with carbohy- 
drate fermentation. In children with thread worms the condition 
too is found, and in adults scratching, for the relief of pruritus ani, 
may precipitate the eruption. Whatever the cause, the process need 
not remain limited to the anal region, but may extend to the peri- 
neum, along the entire intergluteal fold, and thence to the adjacent 
portion of the buttocks. In infants, because of careless toilet, an 
acute erythematovesicular dermatitis of the napkin region often 
arises. This, in nurse-maid parlance, is known as chafing and re- 
flects largely on the carelessness of the child's attendant. 



112 DEKMATOLOGY 

Genital Dermatitis (Eczema). The penis, scrotum, vulva and 
adjacent areas vary in their response to dermatitis according to cer- 
tain anatomical peculiarities. When the prepuce is involved acutely 
it swells and may cause phimosis and balanitis. Acute and chronic 
forms on the shaft of the penis and scrotum conform to the general 
type, but the weeping and lichenified varieties are the commonest, 
and the scrotum often becomes elephantiastic. All forms are seen 
on the vulva, the most frequent being the weeping and lichenified. 
Vaginal discharges intensify and protract the disease, and involvment 
of the mucous surface of the greater and lesser lips and the introitus 
are the rule rather than the exception. Perspiration, too, augments 
the condition and, almost invariably, the itching is intense. Macera- 
tion results, and this with weeping and scaling greatly increases the 
difficulty of epidermal regeneration. These regions are involved in 
a great proportion of the infantile forms of the disease. 

The Umbilicus presents a variety modified by maceration. Any- 
where else the form most frequent here would simply scale, but 
the moisture, as between the toes and about the genitals, converts 
the scales into lamellae which are easily removed, leaving a humid 
red surface. 

The Nipples are attacked by vesicular, scaling and particularly 
rhagadiform types of the malady and the process ordinarily extends 
to and beyond the areola. Women are attacked almost exclusively 
and particularly during the period of lactation. The relationship 
of this form of dermatitis to Paget's disease will be discussed in con- 
nection with epithelioma (Chapter XXIX). 

The Flexor and Body Folds. Surfaces in constant contact, as 
below the breasts, abdominal folds in the obese, the femoro-scrotal, 
and labial junction, the axillae, because of friction and moisture, are 
liable to erythematous, weeping, macerated, scaling and rhagadiform 
types of the malady. The elbow and knee flexures, where the integu- 
ment is particularly thin and sensitive, are similarly involved, and 
also frequently by lichenified forms which simulate lichen simplex, 
and which, in fact, were considered identical with the latter by the 
Germans who called the condition eczema flexurarum. Forms de- 
veloping in cutaneous folds are known as intertriginous. 

IV. Varieties Determined by Causation. 

To introduce this grouping at this point is perhaps a trifle pre- 
mature since the question of etiology has not yet been discussed. 
Thus, for the present, slightly dogmatic statements will have to be 



VESICULAK DISEASES 113 

permitted. In the paragraphs on causation many features which 
appear unrelated will be brought into harmony. 

1. External Origin; Dermatitis Venenata. 

This condition is produced by a great many external agents of 
which several examples are appended. 

A. Chemical. 

(a) Vegetable; poison ivy, poison sumach, nettles, primroses, 

croton oil, cantharides, mustard, arsenic, turpentine, tars, 
vegetable dyes, resins, et cetera, 

(b) Animal; rancid fats as in soap and ointments; certain in- 

sects as the brown-tailed moth ; secretions and excretions 
as urine, feces; discharges from the body emunctories 
and cutaneous glands. 

(c) Chemicals; anilin dyes, mercury, salts, iodine and its de- 

rivatives, hair dyes, hair washes, picric and chromic 
acids, phenol, formalin, perfumes, mouth washes, chiefly 
those containing peppermint and wintergreen, dichlor- 
amin T and Carell-Daikin solution, et cetera. 

All substances employed in art, science, and the most diverse voca- 
tions are capable of provoking a dermatitis in given individuals. 1 

Two types of the disease, because of their frequency, require more 
detailed mention. The first of these is ivy poisoning, the second is 
occupational dermatitis, also known as professional eczema. The 
majority of external irritants which cause dermatitis produce that 
variety which is best illustrated by a description of poisoning by rhus 
toxicodendron. It is supposed that toxicodendric acid is the ex- 
citant. After exposure to this ubiquitous plant the patient becomes 
aware of intense burning or itching. In mild cases a few vesicles 
appear, while in severe ones the affected skin becomes red, swollen 
and thickly studded with vesicles and small bullae. The face fre- 
quently is edematous beyond recognition, the eyelids closed, the lips 
puffed. After from two to five days the vesicles rupture, crusts 
form, the swelling diminishes, the erythema fades and desquamation 
begins. In a fortnight or three weeks recovery is complete. At 
times the disease persists much longer, however, in a subacute or 
chronic form, which tradition still compels us to call eczema. 

Carell-Daikin solution and dichloramin T when improperly used 

i For a complete list of these substances consult James C. White's extensive 
Monograph — "Dermatitis Venenata," Boston, 1887, Cupples and Hurd. 



114 DERMATOLOGY 

may cause an erythematous, papular or even a papular and vesicular 
rash. This occurs in susceptible individuals in the neighborhood of 
sinuses being treated with the above substances, when the surround- 
ing skin has not been protected by petrolatum or a paste of the Lassar 
type, and while in the army, I often saw examples of the eruption 
in question. Normal tissue seems often to be adversely affected by 
these antiseptics, although they certainly do not appear to irritate 
pathological tissue. In one instance dichloramin T was used by an 
officer as a mouth wash for an attack of herpes. Within an hour or 
so he got an acute exudative cheilitis, and his entire buccal mucosa 
was swollen and painful. A young officer with osteomyelitis of the 
small bones of his feet invariably, when dressings of these substances 
were locally applied, developed not only a dermatitis at the sites thus 
dressed, but a generalized erythomato-vesicular eruption which lasted 
for a few days, and itched and burned intensely. Such experiences 
were rare, however. The common eruption seen was that of a weep- 
ing, infiltrated dermatitis framing the wound in a margin up to an 
inch in breadth. This always slowly disappeared when treated with 
Lassar's paste or a bismuth paste. Nor have I ever seen the condi- 
tion arise at all in patients, the neighborhood of whose wounds has 
been protected with petrolatum or some other fat. As a corollary to 
the above it is obvious that these substances have no value in the 
treatment of pure dermatoses. 

Occupational dermatitis is usually confined to the hands, in par- 
ticular the dorsum, and is seen among factory workers, artisans, 
surgeons, trained nurses, et cetera. It may and often does resemble 
ivy poisoning. Equally often it is more like nummular, or inter- 
digital dermatitis, or a rhagadiform squamo-vesicular dermatitis of 
the fingers and palms. The subjective symptoms may be intense. 

B. Physical. 

Cold may cause a scaling fissured dermatitis known as " chapping." 
The face, lips and hands are subject to this, as well as the leg above 
the shoe tops. Heat and particularly sunburn, for which the actinic 
as well as heat rays are responsible, causes erythematobullous der- 
matitis followed by scaling and hyperpigmentation known as tanning. 
The Roentgen rays rarely cause vesiculation, but among other 
changes produce erythema and increased pigmentation. Pressure, 
of clothes or artisans' implements, is also capable of producing the 
disease. A common example of this form is seen in individuals 
wearing braces, trusses, splints and surgical dressings, and in the 



VESICULAR DISEASES 115 

last type irritating secretions from wounds augment the intensity of 
the process. 

2. Internal Origin - . 

The commonest variety of this group is that associated with dia- 
betes. It may assume any clinical form. Nephritis, chronic con- 
stipation, particularly in the presence of proteid putrefaction, prob- 
ably sensitization to certain foods, and endocrinous disturbances are 
also more frequently at fault than we suspect, or with our present 
methods of study, are able to demonstrate. 

3. Local Predisposing Causes. 

A great deal has been written of seborrhoeal eczema and dermatitis. 
The nature of seborrhoea will be discussed subsequently (Chapter 
XI). Suffice it to say that although seborrhoea is no eczema, eczema 
or dermatitis often develops on seborrhoeal areas. Ichthyosis is a 
rare cause of the disease. Hyperidrosis, sudamina and pompholyx 
are frequent contributing causes, and the malady is often observed 
with prurigo, dermatitis herpetiformis and scabies. Varicose veins 
predispose to dermatitis of the leg. 

4. Unknown" Causes. 

Probably the term eczema, if justifiable at all, is so only as applied 
to varieties of undetermined causation. My own belief is that it 
would be sounder to eliminate the term and substitute dermatitis of 
unknown origin, since dermatitis is a descriptive word and eczema a 
symbolic expression connoting nothing definite. This, however, is a 
heresy for which we are not yet ripe. The entire question will be 
referred to in greater detail under the heading of etiology. 

V. Varieties Determined by Age. 

Although no period in human life is characterized by immunity to 
dermatitis, the process varies somewhat according to the patient's 
age. Infancy and senility both possess fairly striking forms. 

Infantile Dermatitis (Pig. 14) usually begins in the first months 
of life and may be limited or very extensive. As a rule it arises on 
the scalp, extending thence to the face and neck, and frequently to 
other parts of the body, favoring the flexors and those other skin folds 
peculiar to babies. It readily weeps and crusts, and because of the 
susceptibility of the infant skin to pyogenic organisms, impetigo 



116 DERMATOLOGY 

frequently develops. When the malady is severe the baby's face, 
head and neck are covered with a seropurulent discharge from in- 
numerable vesicles, pustules and weeping surfaces. Crusts, scales, 
erythematous patches and bleeding excoriations form. Similar man- 
ifestations may arise anywhere else. Lichenification is rarely if ever 
present. 

The etiology of the disease has been discussed in a voluminous 
literature and has stimulated a great amount of investigation. The 
result of all of this effort in terms of actual knowledge is slight. 
Infants, in general, live either on maternal or cow's milk so that a 
dietetic fault, it would appear, should be easy to demonstrate. It 
has been held that either the fats, carbohydrates, proteids^ or salts 
are responsible. Sensitization to the various milk proteids has also 
been considered. Another explanation has been the famous exuda- 
tive diathesis. ~No one theory satisfies all cases, and each view seems 
correct in some instances. When these have been totaled, however, 
a substantial balance remains about which we have no certain knowl- 
edge. Undoubtedly, this ignorance will vanish as methods of bio- 
chemical investigation improve. Local cutaneous disturbances, too, 
are involved in the production of the disease, the chief of which is 
seborrhoea. Very few infants fail to show some evidence of this 
condition, from a mild crusting of the scalp (the so-called milk 
crusts) to a more extensive involvement of the face, and even the 
body, and this favors exudative inflammations. 

Senile Dermatitis. The salient feature of the disease at this 
age is a degree of pruritus often out of all proportion to the extent 
of the area involved, or the severity of the lesions. Any or all of 
the clinical types may be present, the squamous and lichenified being 
the most frequent. The face, genital organs, arms and legs appear 
to be the sites of election, but any other portions of the body may 
be and often are affected. The intractability of the disease forces 
the conclusion that it depends upon profound metabolic disturbances 
incidental to old age, and the problem of relief is one with that of 
the discovery of the fountain of youth. 

Differential Diagnosis. A disease capable of assuming so many 
aspects imitates and must be differentiated from many other condi- 
tions. To facilitate the process of differentiation, the various clin- 
ical stages will be compared in order with the diseases simulated. 

Erythematous 3 

Localized on Face 

Eosacea — (Chapter XXXV). 



VESICULAK DISEASES 



117 



Vesiculobullous 



Disseminated 

Scarlatina, Measles and Various Toxic 
Eruptions — (Chapter VI). 

Localized 

Erysipelas — (Chapter XXIII). 
Herpes — (This Chapter, above). 
Zoster — (This Chapter, above). 
Pediculosis Capitis — (Chapter XX). 
Kingworm— (Chapter XXXVII). 
Favus — (Chapter XXXVII). , 



Vesiculopustular 



Papular 



Squamous 



Disseminated 

Scabies — (Chapter XX). 
Pediculosis Corporis et 

(Chapter XX). 
Pemphigus — (Chapter X). 



Pubis 



Impetigo Contagiosa — (Chapter 

XXIV). 
Impetigo Bockhardt — (Chapter 

XXIV). 
Sycosis — (Chapters XXIV. and 

XXXV). 

Acute Lichen Planus — (Chapter 

XIII). 
Prurigo — (Chapter VII). 

Localized 

Lupus Erythematosus — (Chapter 

XXV). 
Squamous Palmar Syphiloderm — 

(Chapter XLH and XLHI). 
Eczema Marginatum — (Chapter 

XXII). 
Erythrasma — (Chapter XXII). 



Disseminated 

Psoriasis — (Chapter X). 

Parapsoriasis — (Chapter X). 

Pityriasis Eosea — (Chapter X). 

Pityriasis Versicolor — Chapter 
XXII). 

Lichen Acuminatus — (Chapter 
XIII). 

Premycosis — (Chapter XXVI). 

Pityriasis Eubra of Hebra — (Chap- 
ter XII). 



118 DERMATOLOGY 

Rosacea (Fig. 79) is a red eruption of the face, confined to the 
nose, the adjacent areas of the cheeks, the chin, and the forehead. It 
is characterized at first by dilatation of vessels, and these persist show- 
ing through a diffusely erythematous integument. A more or less 
marked oiliness of the skin develops and frequently pustules arise 
resembling those seen in acne vulgaris. After meals, particularly 
when spicy or hot food has been eaten, the face flushes. Xo scaling 
is present, however: the disease is of insidious onset without vesicula- 
tion or weeping, and it does not itch, although it often is accom- 
panied by a sensation of burning. Dermatitis (eczema), even when 
present at the sites usually affected by rosacea, has, amidst the 
erythematous elements, vesicles and scales, but no telangiectasia. 
Itching is frequent, rather than burning ; there is no flushing and no 
acne pustules develop. It must be remembered, however, that some- 
times irritants employed in treating rosacea may excite, a secondary 
dermatitis. 

Scarlatina, and Measles resemble the mottled erythematous 
forms of dermatitis (eczema), especially in children. The char- 
acteristic systemic symptoms of the exanthemata, their duration, 
and their failure to show vesicles clinically should prevent con- 
fusion. 

Erysipelas is at times strongly suggested by acute vesiculobullous 
dermatitis (eczema) when the latter is limited in extent. The re- 
semblance is due partly to the vivid red of erysipelas, but this alone, 
without vesiculation, could cause no doubts. TVhen vesicles and 
bullae form, the diagnosis of erysipelas depends upon the systemic 
reaction, fever, malaise, or depression, the sharply limited margin, 
induration, edema, and characteristic peripheral advance of the 
lesion. Fever in dermatitis is low, if present at all ; the patches 
fade into the normal skin by gradation ; edema may be marked, but 
there is little or no induration, and it is comparatively rare to have 
serious systemic symptoms. The vesicles and bullae are much more 
numerous in dermatitis than in erysipelas. 

Herpes (Tig. 9). Small patches of dermatitis (eczema) when 
composed of groups of vesicles, strongly simulate simple herpes, 
when areas are involved in which the latter is prone to occur. 
Herpes, however, is preceded by a sensation of tension and burning, 
rather than pruritus. The vesicles are deep-seated and rupture with 
difficulty and the patches are usually single, or, when multiple, fol- 
low a line of nerve distribution. In dermatitis and eczema the 
patches are numerous and do not follow the course of nerves. Iso- 



VESICULAR DISEASES 119 

lated islands of this condition are rare. Herpes does not weep or 
scale, but involutes by desiccation. 

Zoster (Fig. 10). The sudden outbreak of a rash after a pro- 
dromal period of several days of pain, usually severe and often 
agonizing, the typical distribution and mode of fading are all suffi- 
ciently distinctive to rule out dermatitis, save for the fact that both 
are vesicular diseases. The grouping of the vesicles in zoster is com- 
pact and the lesions are deeper and prevailingly larger. 

Pediculosis Capitis. At times pediculi of the scalp cause a 
vesicular dermatitis of the face, neck, ears and scalp, itself. This 
differs in no way from any other dermatitis, save that it more readily 
becomes impetiginous. It is important, however, to bear in mind 
that dermatitis at the sites mentioned may be due to the epizoa and a 
conscientious investigation to establish their presence, or that of 
nits, should be made. 

Ringworm (Fig. 48). The vesicular forms of ringworm remotely 
simulate dermatitis (eczema) in circular patches. Ringworm pre- 
vailingly occurs in circular lesions, the centre of which tend to be 
scaling or crusted, and the periphery vesicular or vesiculopustular. 
The site most frequently involved is the scalp, although the glabrous 
areas are also affected. The diagnosis is established by demonstrat- 
ing the presence of the micro-organisms. Recently Ornish y has re- 
ported the presence of epidermophyton inguinale in the vesicles of a 
form of vesiculobullous dermatitis of the hands and feet resembling 
pompholyx. (Chapter XXII.) This has already been mentioned 
in paragraphs dealing with the hands and feet. 

Favus simulates dermatitis in only one stage. When the latter is 
vesicular and golden crusts appear, these suggest the sulphur-colored 
scutula of favus. The crusts are not cup-shaped, however, and the 
achorion is absent. 

Scabies (Fig. 43). Generalized pustulovesicular dermatitis 
(eczema) somewhat resembles scabies, since scabies frequently be- 
comes " eczematized." The localization, the nocturnal itching, the 
burrows caused by the acari, and finally, the microscopic demonstra- 
tion of the latter are the points upon which the diagnosis rests. 

Pediculosis Corporis (Fig. 44) et Pubis. People afflicted with the 
body louse at times acquire dermatitis. The parallel scratch marks, 
chiefly over the shoulders, but also wherever else the clothing presses 
against the body, the general thickening and pigmentation of the skin 
rather than the presence of papules or vesicles, furnish an ample 
basis for differentiating pediculosis corporis from dermatitis. Find- 



120 DEKMATOLOGY 

ing the lice in the folds of the underclothing clinches the matter. 
Pediculosis pubis, itself, does not cause dermatitis nearly so much 
as does the blue ointment, so universally used in the treatment of 
the disease. 

The inflammation corresponds to the involved hairy areas and the 
diagnosis rests partly upon the history, and partly upon the dis- 
covery of nits or pediculi in the hair. 

Pemphigus (Fig. 17) may but rarely be confused with dermatitis 
(eczema), and then only when the latter exhibits large bullae. Even 
in such an event, however, the fact that pemphigus blebs arise 
from a non-inflammatory base, and the presence of buccal lesions are 
too distinctive to permit of much confusion. Pemphigus foliaceous 
may remotely resemble the weeping and scaling stages, but the ad- 
mixture of blebs and the severe constitutional reaction would exclude 
this possibility. In this connection it must be remembered that 
dermatitis herpetiformis, closely related to pemphigus, may also re- 
semble simple dermatitis. The vesicles in dermatitis herpetiformis 
are inclined to be grouped herpetically, and involute by desiccation. 

Impetigo Contagiosa in its pure form does not resemble dermatitis 
(eczema) but the latter is capable of becoming secondarily infected, 
or impetiginous. It is important, in connection with impetigo, to 
determine its underlying cause. Any vesiculobullous, rhagadiform, 
or excoriated dermatosis may be the starting point. Obviously, 
dermatitis is among these. Impetigo and dermatitis are both 
vesiculobullous, serum exudes from the lesions, and crusts form. 
The lesions of impetigo are prevailingly bullous, however, rapidly 
become purulent, the crusts are honey colored, the weeping transitory, 
the course short, the disease is almost entirely restricted to children, 
and favors the face or scalp. Ecthyma is a form of impetigo which 
involves the skin more deeply, leaving punched out ulcerations. In 
general, though, what is true of impetigo holds in ecthyma as well. 

Impetigo of Bockhardt is a suppurative folliculitis of the scalp and 
is closely related to sycosis non parasitaria better called folliculitis 
staphylogenes barbae. Because of the similarity of the small pus- 
tules to infected vesicles, a certain resemblance exists to vesiculo- 
pustular dermatitis. Close inspection of the lesions, their intimate 
restriction to the follicles, their pure pustular character, and the fact 
that the lesions are pierced by hairs, rule out any other diagnosis 
than that of impetigo or sycosis. 

Lichen Planus. Save for the acute generalized form of lichen 
planus there can be no confusion between this disease and dermatitis, 



VESICULAR DISEASES 121 

and only the disseminated small vesicular or vesiculobullous form of 
the latter can create such confusion. Close inspection of the nature 
of the lesions immediately indicates how easy of differentiation the 
two are. The lichen lesion, in the disseminated forms of the dis- 
ease, is a minute, glistening, waxy, chrome papule, umbilicated and 
highly pruriginous. ~No vesiculation exists. The dermatitis papule 
is a small, solid, dull red and slightly lenticular lesion. In lichen, 
the buccal mucosa is frequently the site of minute, pure white lesions, 
totally wanting in the other disease under consideration. 

Prurigo is papular urticaria. It usually begins in childhood, per- 
sists indefinitely, and is characterized by the presence of minute, 
shotty papules, some of which have a pinpoint vesicular summit. It 
is localized prevailingly upon the extensor aspects of the limbs, the 
buttocks and belly, and the skin as a whole becomes thickened. It 
is unattended by large areas of vesiculation or scaling, and the glands 
enlarge throughout the body. 

Lupus Erythematosus. For the most part this disease involves 
the face and scalp, usually in bilateral symmetrical distribution. 
The lesions are scaly placques of purplish red, the margins have 
greasy adherent scales the under surfaces of which possess short pro- 
jections or plugs, casts of the patulous follicles in which they arise. 
Ultimately, an atrophy remains at the site of the lesions. In der- 
matitis the scaling occurs on a generally slightly erythematous sur- 
face, and often evidences of vesicles remain. ISTo atrophy occurs. 

Squamous Palmar Sypliiloderm (Figs. 90 and 95). Squamous 
lesions are seen in the secondary and tertiary stages of syphilis. 
Those observed in the former cannot readily be confused with squa- 
mous dermatitis ; those arising in the latter can, and it is often almost 
impossible to differentiate the two. The syphiloderm is usually, 
but not always unilateral, and it never itches, but at times the scaling 
dermatitis of the palm does not either. Frequently the syphiloderm 
has the characteristics of grouping known to syphilis. Often enough 
the outline is irregular, fissures form, the epidermis is thickened as 
in dermatitis, and the scales are irregular in size and shape. A pos- 
itive Wassermann reaction and other evidences of syphilis are re- 
quired to settle the diagnosis, but if the serum test should be negative 
as sometimes is the case in the tertiary stage, vigorous general, with- 
out local, antisyphilitic therapy as a diagnostic procedure, may clear 
up the question. 

Eczema Marginatum (Fig. 52) (Epidermophytia Inguinalis) is a 
disease of the scrotum, more rarely the vulva, the adjacent portion of 



122 DERMATOLOGY 

the thighs, the axillae, and the folds formed by the breasts and chest. 
It is a red squamous slightly itching disease, closely resembling der- 
matitis of the areas mentioned, and it consists primarily of nummular 
lesions which gradually coalesce into placques with a festooned out- 
line. The diagnosis can be settled by demonstrating the causative 
fungus — one of the trichophytons. The cause of this variety is 
the epidermophyton inguinale and it is related to the form seen on 
the hands and feet, already described. 

Erythrasma affects the same areas as eczema marginatum, and 
consists of diffuse patches of a buff or copper color which scale and 
have a sharply circumscribed margin. It is caused by a fungus, 
the microsporon minutissimum. The diagnosis often can be made 
only by demonstrating the organism. 

Psoriasis resembles patchy, scaling dermatitis (eczema) partic- 
ularly when associated with seborrhoea. This is especially true 
when itching is present, as occasionally occurs in psoriasis. The 
scales in the exfoliative stages of dermatitis are finer than in 
psoriasis, not laminated and not clear white, and associated with them 
may be other elements of a process such as vesiculation, which are 
totally lacking in psoriasis. The purpura and punctate bleeding, 
on removing scales, are characteristic of psoriasis, but lacking in the 
other condition. Finally, in even the least characteristic forms of 
psoriasis, some typical elements are present at the classical sites, 
which clearly indicate the nature of the disease. 

Parapsoriasis does not itch, never has a vesicular stage, runs a 
chronic and prolonged course, has very fine scales, and only on most 
superficial inspection can be confused with dermatitis. Parapsor- 
iasis always evades the head. 

Pityriasis Rosea resembles that form of dermatitis or eczema 
which arises on seborrhoeal skin. At times, the most experienced 
dermatologists are unable to differentiate between the two conditions. 
In typical cases of pityriasis rosea the early lesions are pink, the 
later ones have a tan or buff centre, and a scaling pink periphery. 
It is rare to see lesions above the neck, or below the middle third 
of the thigh, and somewhere on the body, usually on the lower 
abdomen or back, one lesion, much larger than the rest, is seen. 
This lesion is the starting point of the disease. In general, too, the 
condition appears to be epidemic in the spring and fall. 

Pityriasis Versicolor also remotely resembles those forms of scal- 
ing dermatitis which arise in connection with seborrhoea. The like- 



VESICULAK DISEASES 123 

ness is superficial and if necessary a demonstration of the pathogenic 
agent of pityriasis versicolor, the microsporon furfur, clinches the 
diagnosis. 

Lichen Acuminatus in its exfoliative stages, particularly when it 
forms placques, can resemble lichenified scaling patches of dematitis. 
The finding of typical papules admixed with patches of lichen acum- 
inatus, particularly on the dorsum of the fingers, the scales adherent 
to the papules, the absence of vesiculation determine the diagnosis of 
lichen. 

Premycosis: Mycosis, or Granuloma Fungoides, has an initial 
stage one form of which is indistinguishable clinically from chronic 
dermatitis. The prefungoid patches, however, are a trifle more cir- 
cumscribed and much more pruriginous than are those of the other 
condition, and microscopically, often possess a granulimatous struc- 
ture. Many cases of mycosis begin with what at first seems to be a 
harmless dermatitis, and only the course of the disease reveals 
its actual nature. 

Pityriasis Rubra of Hebra and the other erythrodermas are capable 
of simulating a generalized dermatitis. It is indeed rare, however, 
for the latter to be universal as are the erythrodermas. Moreover, 
the scaling in these exfoliative dermatoses is coarser, more profuse 
and more persistent, and is not consecutive to vesiculation. Their 
constitutional symptoms are pronounced, the skin in general thickens, 
and weeping is rare. The entire integument from top to toe is 
covered, and while dermatitis may involve all areas of the body it 
does so by virtue of wide distribution of the lesions, which practically 
never exist universally and uninterruptedly. 

Etiology and Pathogenesis. 1 The problem of the etiology of 
the disease has stimulated much investigation and more writing. 
Our views concerning the question are not yet in accord. It is 
variously contended that : 

1. Eczema and simple dermatitis are two distinct conditions; 

2. Eczema is invariably of internal origin; 

3. Dermatitis is invariably of external origin ; 

4. Either disease may be of either origin ; 

i For a detailed review and bibliography of this question, see Pusey's " Text- 
Book on Dermatology " ; Brocq's " La Question des Eczemas," Annal de Dermat. 
et de Slph., January — March, 1900; Besnier, " Pract. Dermat.," Vol. II., P. 1; 
Heimann, " A Critical Review of Eczema and Dermatitis," Journ. of Cutan. Dis. 
Vol. XXXIV., No. 4, PP. 259-284; and Jour. Amer. Med. Assoc, Vol. LXVII. 



124 DERMATOLOGY 

5. Dermatitis is a cutaneous catarrh of known external or internal 

origin, and eczema a cutaneous catarrh of unknown external 
or internal origin; 

6. Eczema is dermatitis of unknown origin. 

The internal causes of eczema have been regarded as : 

1. Diathetic — heredity, constitutional weakness, gout, diabetes, 

et cetera; 

2. Physiological — infancy, dentition, pregnancy, lactation, senility; 

3. Nervous; 

4. Functional and Organic — digestive, urinary and assimilatory : 

5. Disturbances of metabolism and of the endocrinous glands. 

The local causes of eczema have been considered : 

1. Cutaneous anomalies such as ichthyosis, hyperidrosis, seborrhoea, 

skin folds, body orifices ; 

2. Chemical and physical irritants; 

3. Micro-organisms. 

The local causes of dermatitis have been considered : 

1. Chemical and physical irritants; 

2. Micro-organisms. 

Before proceeding with a discussion of these numerous and dis- 
similar factors, it is necessary to understand the pathology of the two 
conditions. Clinically, as has been pointed out, they are identical. 
Microscopically, the same holds true. Both are catarrhal inflam- 
mations ; both are exudative. Thus, histologically, eczema is simple 
dermatitis. What then are the differences, if any, between the two 
processes ? In the disease commonly known as simple dermatitis, 
there is a history of known exposure. Is this enough to differen- 
tiate it clinically from eczema? For an answer, the doctrine of 
cutaneous reactions (Chapter III) must be re-emphasized. Just as 
wheals may be due to innumerable causes constituting the picture of 
urticaria, so are the lesions of (eczema) dermatitis. Precisely as 
wheals are provoked both by external and internal causes, so are the 
lesions of (eczema) dermatitis. 

Further facts must be borne in mind. All individuals are con- 
stantly exposed to cutaneous irritants — whether physical or chem- 
ical. A relatively small proportion of the human race ever shows 
any ill results therefrom, else every surgeon would have bichloride 



VESICULAR DISEASES 125 

dermatitis, every workman some occupational dermatosis, and every- 
one exposed to rhus would have dermatitis. Examples might he 
cited indefinitely. All of this indicates that the majority of human 
beings are incapable of being harmed in the manner mentioned. 
They are immune. From this it follows that susceptibility means 
predisposition, and predisposition indicates a variation from the 
normal which may be congenital or acquired. Two factors then are 
necessary to produce dermatitis, a predisposing or general and a 
precipitating or local cause. 

Diabetes is one of the general diseases capable of causing derma- 
titis. There are many others also, but diabetes will excellently 
illustrate the influence of internal derangements in the pathogenesis 
of the malady. Not every diabetic, however, acquires eczema. 
Why ? Because the skin is not equally liable to the disease in all 
individuals. This means that a precipitating cause must exist in 
those who become afflicted. What then is the difference between 
two conditions which are identical clinically and microscopi- 
cally, but one of which is due to a known local and undetermined 
general cause, and the other to a known general and undetermined 
local cause? Actually none. Inability to detect the unknown 
quantity does not exclude the existence thereof, but simply denotes 
ignorance or inadequate scientific methods on the part of the observer. 
Such a deficiency supplies no rational grounds for the creation of 
two disease entities, and we are forced to the conclusion that since 
eczema is dermatitis, and since not all the causes of dermatitis are 
known, eczema, if we wish to use the term at all, is dermatitis of 
undertermined origin. Thus, it ceases to be rational to retain such a 
word as eczema, but it is inevitable that we must remember what it 
signifies, since the term has been used in all previous literature. 
We may restrict its scope to dermatitis of unknown origin. We 
might as well, however, call nephritis, or colitis, or gastritis of 
unknown origin, eczema of the kidneys, colon, or stomach. 

The local causes of dermatitis are: 

1. Chemical. Acids, alkalies, salts, caustics, cleansing fluids, powders, 

soaps and cosmetics — in short, all materials used in any vocation 
or phase of life. 

2. Vegetable Substances. Rhus, primrose, poison sumach, wood oils, and 

many others — forty-six families in all. 

3. Animals and Animal Substances. Brown-tailed moth, pediculi, acari, 

cantharidis, ants, and many less common varieties. 

4. Micro-organisms. 

a. Bacteria, staphylococci (?). This on the whole has never been 



126 DEKMATOLOGY 

proved. (See the Transactions of the Fourth International 
Dermatological Congress.) Possibly bacterial toxins or the 
bacteria themselves may intensify the process. Engman's in- 
fectious eczematoid dermatitis is due to a staphylococcus, 
b. Fungi. Ormsby and others have isolated a fungus from lesions 
resembling pompholyx. 

5. Physical Causes. 

a. Actinic rays — X-ray and sun dermatitis. 

b. Thermal — Burns and frost-bite. 

c. Trauma — friction from clothes, implements, et cetera. 

6. Undetermined. 

The general causes are: 

1. Metabolic — Disturbances of nitrogen metabolism (nephritis), sugar 

metabolism (diabetes), or of the glands of internal secretion, par- 
ticularly hyperthyroidism. 

2. Digestive and Assimilatory — Gastritis, hyperacidity, achylia, bread 

dyspepsia, carbohydrate fermentation, proteid putrefaction, constipa- 
tion, enterocolitis, fat indigestion. 

3. Eliminatory Diseases — Chiefly nephritis. 

4. Hematogenic — The anemias and leukemias. 

5. Anaphylactic — Intolerance to proteids. 

The so-called reflex causes — dentition, menopause, menstrua- 
tion and nervous — can properly be included in the metabolic group. 
It is difficult to conceive of the way in which the nervous system 
by being deranged might cause dermatitis, unless some forms thereof 
were trophoneuroses, a view for which no valid evidence exists. My 
own experience leads me to believe that the commonest internal 
causes of conditions with which dermatitis is associated are disturbed 
nitrogen or sugar metabolism, hyperthyroidism, the entire group of 
digestive and eliminatory disturbances, badly tolerated food-stuffs, 
and sensitization to certain proteids. Of all of these, the most fre- 
quent are proteid putrefaction and constipation. 

Local predisposing causes are ichthyosis, hyperidrosis (related 
to pompholyx and prickly-heat), skin folds (related to intertrigo), 
body orifices (related to dermatitis about the mouth, anus, vulva, 
perineum) . The scalp, eyebrows and eyelids are also peculiarly vul- 
nerable, and finally it must be remembered that in certain individuals 
areas far from body folds or orifices, or free from any anomalies or 
other cutaneous disturbances clinically recognizable, are subject to 
the malady.. Whether this is due to chemical or anatomical pecu- 
liarities is hard to determine. In interpreting the contents of this 
paragraph it is obvious that local predisposing causes must be 



VESICULAR DISEASES 127 

summed up in the scientific symbol of points of lowered resistance. 
Local predisposing causes may act in three ways. They may assume 
the function of precipitating causes in the presence of general dis- 
turbances ; retain their role of predisposing causes in the presence 
of external precipitating causes; or, act as the hypersusceptible 
medium in which external causes operate with maximum intensity 
in individuals with a general predisposition. Thus, eczema is 
dermatitis, and dermatitis depends upon an interplay between various 
known and unknown local and predisposing causes. 

Treatment. The external treatment of dermatitis or eczema 
differs according to the stage of the disease, its situation, according 
to individual peculiarities of the lesions, and symptoms. The inter- 
nal treatment depends upon the general cause, if there is one that 
can be determined. The first point of importance to settle is the 
presence of a local precipitating cause. Thus, the patient must be 
interrogated as to occupation, habits, pastimes, the recent acquisi- 
tion of new clothing, the use of cosmetics, hair lotions, soaps and 
powders. By this means only may occupational dermatoses, and 
those of chemical and physical origin be recognized. Scales and 
secretion from vesicles must be examined for fungi, so that derma- 
titis due to such organisms may be recognized. Inquiry and clinical 
and pathological examinations must be made to determine the pres- 
ence of digestive, eliminatory, gynecological, metabolic, and endoc- 
rinous disturbances. If the work of 0. J. White in the percuta- 
neous test in the disease bears out its promise, a valuable diagnostic 
aid will have been established. Internal treatment must be guided 
by the above considerations. 

The digestive tract appears most frequently at fault, but it 
is difficult to be sure whether this is cause and effect, or whether 
the skin and intestinal conditions are both expressions of a common 
underlying cause. In any event, the method of attack here is to 
modify the diet subject to the presence of carbohydrate fermenta- 
tion, proteid putrefaction, simple constipation, hyperacidity, achylia, 
et cetera. In addition, the use of mineral oil for constipation, 
daily colon washings, particularly for chronic intestinal intoxication, 
and the suitable employment of cathartics and eliminatives are in- 
dicated. For intense pruritus, especially in high-strung patients, 
the bromides and valerian preparations are of great value. It 
must be remembered, however, that the bromides and opium 
derivatives, useful as they usually are, themselves may cause itching 
in certain people, and unless they produce a very marked and prompt 



128 DERMATOLOGY 

antipruritic effect, they are to be discontinued. Furthermore, con- 
stipation frequently results from the use of opium which must 
therefore be employed guardedly. If nephritis should appear to be 
responsible for, or associated with the dermatosis, suitable treat- 
ment of the kidneys obviously is indicated, but diaphoretics are not, 
since stimulation of the sweat apparatus would probably irritate 
the skin. When excretion of nitrogenous end substances of metab- 
olism is lowered by renal impairment, the patient must be put to 
bed, and the main indication becomes that of the renal disturbance. 
After restoring the powers of elimination so far as possible, the 
treatment of the skin again becomes the more prominent problem. 

Local Treatment. Acute Dermatitis (Acute Eczema). The 
therapeutic problem is the control of an acute exudative inflamma- 
tion, the phenomena of which are swelling (edema and vesicles), 
congestion (erythema), pain (itching and burning) and local heat. 
The means of accomplishing this correspond with those employed 
for any similar process anywhere within the body. So far as pos- 
sible the affected part must be put at rest. Thus, when the involve- 
ment is extensive, the patient should go to bed, or at least lie down. 
The remedies indicated are wet dressings, soothing lotions and 
pastes. The use of ointments is contra-indicated. The following 
medicaments are the best to be used as fomentations ; viz. : Bur- 
row's solution (alum acetate), resorcin lotion, magnesium sulphate, 
or witch hazel. Burrow's solution should be diluted with nine 
volumes of cool water, and bulky dressings should be applied to the 
affected parts constantly for from twenty-four to forty-eight hours; 
or until the swelling and erythema are reduced. This treatment 
should not be used at night if it interferes with sleep. Impervious 
substances to cover the dressings are emphatically contra-indicated, 
as the value of fomentations in acute vesicular processes depends 
in a large measure upon evaporation. Weak resorcin solutions are 
keratoplasty and antipruritic. Wet dressings of this substance in 
one to two percent, strength may be employed precisely as Burrow's 
solution, but resorcin should not be used about the eyes as it may 
cause severe conjunctivitis. Magnesium sulphate is employed in 
half saturation in water as hot as the patient is able to bear, and 
the dressings are applied for from fifteen to twenty minutes every 
two hours, followed by a soothing lotion. Witch hazel is diluted 
with equal parts of hot water and used exactly as magnesium 
sulphate. 

During such periods as the wet fomentations are interrupted, 



VESICULAR DISEASES 129 

as at night, or in the intervals following the magnesium sulphate 
or witch hazel dressings, the skin is to be coated with a soothing, 
shaking lotion of which the following are types : 

Powdered Calamine aa. . . 10.0 

Zinc Oxide 

Alcohol . ., 50.0 

Rose Water to 200.0 

Sig. 

Zinc Oxide 

Powdered Calamine aa. . . 10.0 

Alcohol 50.0 

Rose Water 20.0 

Lime Water to 200.0 

Sig. 

A lotion of this sort must be thoroughly shaken up, poured into the 
hollowed palm of the attendant and splashed on the affected surface 
where it dries. It leaves a powdery coating which should not be 
removed save that it is wise to cleanse the skin once in twenty-four 
hours with olive oil. In doing so, however, no great force should 
be employed and only such crusts and coatings of dried lotion should 
be removed as come off easily. Burnt heavy magnesia may be 
substituted for the calamine, and it is somewhat more soothing. 
Ichthyol, in a concentration of from five to ten percent., may also 
be included in the formula. This substance tends to constrict the 
vessels and thus diminishes the congestion. Of the two formulas 
given the second is more astringent and the first more soothing. 
Thus, the second is preferable in the more vesicular and erythema- 
tous types of lesions, but its use must be restricted, as it may dry 
the skin excessively and make it too brittle. At the onset of the 
disease it is often found beneficial to paint the skin with equal 
parts of water and ichthyol. 

When the process has begun to subside wet dressings and 
lotions are no longer indicated, and zinc paste (equal parts of zinc 
powder and vaselin) is substituted. The proper way to employ this 
substance is to spread it evenly and thinly on strips of unbleached 
muslin four to six inches broad which are then applied to the 
affected areas and bound on lightly with ordinary bandages. It 
may be spread directly on the affected surface itself and bandaged 
loosely with muslin. The former method is better. A change of 
the dressings should be made every twelve or twenty-four hours, 
preferably the latter, and the parts lightly cleansed with pure, 



130 DERMATOLOGY 

fresh olive oil, if the paste has dried upon the skin. If the parts 
look clean, however, it is far wiser to omit the oil washing in order 
to irritate the skin as little as possible. Within a week to ten 
days the acute process should have subsided, and subsequent dress- 
ings with ordinary zinc ointment will suffice until exfoliation ceases. 
Should the process have become chronic, the treatment to be pur- 
sued is outlined below. 

Acute weeping and chronic vesicular and weeping dermatitis 
are at first treated as the acute vesicular form. Weeping in general 
is due to imperfect keratinization and thus resorcin fomentations 
are peculiarly useful. Painting of the affected areas with a twenty 
percent., silver nitrate solution is of great value since it promotes the 
growth of epithelium and protects the denuded surfaces. This 
treatment, however, must not be too long continued, or too exten- 
sively applied, because of the danger of argyria. Lassar's paste 
dressings, to be changed every eight hours, are of great value. The 
paste must be applied thickly in order to take up the serum. 
Diachylon paste and ointment are also of signal utility, since the 
lead plaster is a great stimulant of epithelial growth. 

Chronic scaling dermatitis must first be stimulated. The best 
revulsives are tar (oleum Rusci, oleum cadini, liquor carbonis 
detergens, technical coal tar, resorcin, salicylic acid). An excel- 
lent base is zinc ointment. Oleum Rusci is best used in a strength 
of from two to five percent., the other tars in from five to twenty 
percent., resorcin in from two to five percent., salicylic acid in 
from two to three percent. The ointment is rubbed in fairly vigor- 
ously once or twice a day, and when the skin has become thoroughly 
irritated Lassar's paste dressings are used. Roentgen therapy, 1 
Holzknecht unit weekly, hastens the disappearance of these lesions. 
In lichenified eczema, in addition to the treatment just suggested, 
chrysarobin, pyrogallol, eugallol, the first two in five to ten percent, 
strength in vaselin or lanolin, and the last in ten percent, solution 
in acetone are valuable. These provoke a more or less marked 
dermatitis leading to exfoliation. The patient must be warned 
of the danger of these medicaments to the eyes, and of the destruc- 
tive effects of the first two on clothing. Thus, the surfaces treated 
are to be protected, and the patient must be seen daily so that not 
too profound a dermatitis will be excited. 

Special indications arise according to the nature, site and cause 
of the lesions. Dermatitis craquelee is best treated with daily 
inunctions of mild boric acid (two to &ve percent.), or salicylic 



VESICULAR DISEASES 131 

acid (two percent.) ointments once or twice a day. The fissured 
form must be stimulated with silver and dressed with emolient oint- 
ments. Impetiginous forms are best treated at first, in the manner 
of vesicular types, and then with ammoniated mercury ointment, 
two to ten percent. The treatment of lichenoid, weeping, nummular 
and sclerotic types has already been described. Verrucous dermatitis 
(eczema) must be converted into the scaling or lichenified type first. 
This is best accomplished by the use of ten to twenty percent, 
salicylic plaster. Then the treatment becomes that of the lichenoid 
or scaling type. Roentgen rays used as above, are of great value. 

When the scalp is involved in males wet dressings may be 
employed, but this is almost impossible in women. Calamine and 
zinc lotions cannot be used anywhere where there is a long growth 
of hair, nor can pastes. Mild resorcin and boric acid lotions, 
mild boric and ammoniated mercury salves (when these are toler- 
ated) are our only methods of attack. The eyelids may be treated 
with wet dressings of boric acid, salves of mild, ammoniated mer- 
cury ointment (two percent.), or yellow mercuric oxide (one per- 
cent.). When the nares are involved, silver nitrate for the fissures, 
external wet dressings, and white precipitate salve are indicated, par- 
ticularly if there is also impetigo. Labial involvement may be con- 
trolled by the general methods outlined. Tylotic forms (palms and 
soles) are first treated with salicylic acid plaster as above, followed 
by salves and Roentgen rays. Anal eczema is best controlled 
according to the general rules outlined, but if hemorrhoids, pros- 
tatitis, or carbohydrate fermentation are the basis of the skin mani- 
festations, these faults are the essential ones to correct. In children 
with thread worms colon irrigations and white precipitate salve 
should be used. When the genitals are the site of the disease the 
treatment corresponds to that outlined, and in men, balanitis, and 
in women, vulvovaginitis or diabetes are often the basis of the dis- 
turbance. When these conditions are relieved the cutaneous mani- 
festations often vanish without local treatment. Scrotal elephan- 
tiasis is intractable. Umbilical forms, and many of those seen in 
body folds, are treated according to general principles and those set 
forth in connection with intertrigo. The important point is to 
reduce friction as much as possible. 

Special etiological factors also modify therapy. Exposure to 
any external excitant must be prevented. At times, even occupation 
must be changed. Hyperidrosis is best controlled by means of the 
lloentgen rays; seborrhoea, with sulphur or resorcin lotions or 



132 DERMATOLOGY 

salvos, or white precipitate ointment. Infantile forms of the disease 
are often due to digestive disturbances which must, if possible, be 
corrected. That variety due to fungi is best treated by inunction 
twice daily with Whitfield's ointment. 

3. Acid salicylici 2.0 

Acid benzoici 4.0 

ling. aq. Eos. q.s. ad. 30.0 
Sig. 

Prognosis. The prognosis as to life is good. In the majority 
of instances the disease is curable. Forms depending upon occu- 
pation and habit are amenable to treatment only when these are 
changed. Elephantiastic scrotal forms, and those due to varicose 
veins, or varieties dependent upon incontrollable metabolic disorders 
are incurable, but may be improved by proper therapy. Hyper- 
idrotic forms may be improved only when the disturbance of the 
sweat apparatus is amenable to therapy. Here the X-rays are of 
great value. 

DERMATITIS TRAUMATICA 

Scratching, the rubbing of apparel, bites of animals, the use of imple- 
ments and tools, may injure the skin, causing the various well-known types 
of cutaneous traumata. 

Dermatitis Calorica is produced by intense heat, either through heat 
rays, or actual contact with hot substances, such as steam, boiling water, 
oil, et cetera, and fire itself. Slight exposure causes an erythema; more 
exposure, an exudative inflammation with vesicles and bullae ; and still more 
exposure, an eschar with involvement of the deeper tissues. These stages 
are respectively first, second and third degree burns. The last two may 
become infected. Healing takes place with scar formation. When half 
of the body is involved the patient usually dies. The treatment of first 
and second degree burns is that of acute dermatitis. An excellent way 
of handling second and third degree burns is to cover them lightly with 
a single layer of sterile gauze, otherwise leaving the affected areas ex- 
posed. Extensive third degree burns should be treated as surgical wounds. 
If necessary, skin grafting is indicated. 

Dermatitis Congelationis, freezing, or frost-bite, usually involves the 
nose, ears, fingers, toes, feet and cheeks. This process is also divided into 
three stages. In the first there is erythema following ischemia; in the 
second, vesicles and bullae; in the third, gangrene. The intensity of the 
process depends upon the intensity of the cold, and the duration of the 
exposure. Treatment consists of the restoration of circulation by friction 
with snow, or ice. Otherwise, it corresponds to that of dermatitis, or that 
of gangrene, or a wound. People subject to chillblains may prevent these, 
if, beginning in September or October, they practise vascular gymnastics 




HERPES 



Herpes, also known as herpes simplex, cold sore or fever blister, con- 
sists of small areas of grouped vesicles, usually occurring on one side. 
The commonest location is on, or near, the lips or nose. At times, as 
in this case, the buccal mucosa is involved either alone, or in conjunc- 
tion with the skin. At times, the genitals are involved. In contra- 
distinction to zoster, herpes is recurrent and symptomatic, often being 
secondary to an acute infectious disease, notably pneumonia; or follow- 
ing the use of drugs, notably arsenic. Simple herpes is usually quali- 
fied in description by the name of the site, as herpes labialis, progeni- 
talis, etc. 



a% 








Fig. 10. ZOSTER 

Zoster, herpes zoster or shingles, is unilateral and follows the distribu- 
tion of a cutaneous nerve. It thus overruns the mid-line, as this picture 
shows. The lesions are grouped vesicles. In true zoster, recurrences 
are rare, but in symptomatic forms, due to arsenic, or perhaps focal in- 
fections, there may be recurrences. 




Fig. 12. 



DERMATITIS (ECZEMA; 
MADID ANS 



CRUSTOSA OR 



Involuting simple dermatitis crusts and cracks. In chronic 
forms, the skin is thickened. All of these features are here 
illustrated. Crusts are due to serous discharge or weeping. 





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Fig. 13. 



DERMATITIS (ECZEMA), PALMS 
thick, scaling and fissured. It differs 



The integument is thick, scaling and fissured. It differs from 
Imar syphilis in that there are no nodules or large subepidermal 

papules, and there is no festooning of the margins. The soles are 

similarly affected in this form of dermatitis. 




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This illustrates the cutaneous change determined by sustained 
irritation. It is secondary to habitual scratching or rubbing to 
relieve chronic pruritis; or it results from any chronic inflamma- 
tion. In this instance, the cause was specifically dermatitis 
(eczema). Another term is lichenification. The process may be 
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VESICULAR DISEASES 133 

as to the parts usually affected. Thus, the feet every night should be 
plunged alternately five or six times, first into extremely hot and then 
into iced water. Before and after the hydrotherapy the members should 
be massaged with lanolin or vaseline. 

DERMATITIS FACTITIA 

Synonyms. Hysterical, Neurotic, or Spantaneous Gangrene; Feigned 
Eruptions. 

These manifestations are self-inflicted cutaneous injuries provoked by 
the use of caustics, acids, alkalies, various implements, or heat. Eryth- 
emas, vesicles, blebs, superficial gangrene and necrosis are thus caused 
to appear on areas within the reach of the patient's hands. The diagnosis 
depends upon the lack of similarity of the lesions to those of recognized 
dermatoses, and upon the fact that areas are free outside of the range 
of the patient's hands. Often, when caustic fluids have been employed 
to cause the disease, the line of flow indicates its artificial nature. 
Patients have been known to simulate pemphigus, and other skin diseases. 
Malingerers, mendicants, people endeavoring to mystify physicians, to 
excite sympathy, or to evade their duties, are among those in whom the 
disease occurs. At times, no actual reason may be ascertained, but in any 
event the malady indicates mental or moral obliquity. The treatment 
consists in skillfully ascertaining the nature of the disease and confronting 
the patient with the facts. Actual treatment of the lesions varies with the 
nature of their cause, but roughly corresponds with that of dermatitis 
or traumas. 

DERMATITIS REPELS AND ACRODERMATITIS PERSTANS 

These two diseases are probably identical. Both begin after a trauma, 
some occupational injury, a pin-prick, a surgical operation or burn. The 
disease usually starts on a finger or toe, with a more or less persistent 
vesicle or bleb, although frequently without such a prodromal lesion. 
Peripheral spreading of vesicles, and undermining of the advancing margin, 
central denudation of the epidermis, with more or less weeping, charac- 
terize the process. At times, a whole extremity may become involved be- 
fore healing finally takes place. In acrodermatitis perstans, after healing, 
the bleb tends to return at the original site and the process begins afresh. 
In this disease, too, distant areas may be affected, apparently by inocula- 
tion. The cause of the disease is probably an infection and the treat- 
ment consists of that of dermatitis, and the use of strong silver solutions. 



CHAPTER X 

BULLOUS DERMATOSES 

The bullous dermatoses are etiologically not related. Indeed, their 
causation is not definitely explained and they are associated solely 
because of certain similar clinical points. Pemphigus, dermatitis 
herpetiformis, epidermolysis bullosa, and hydroa vacciniforme with 
their subclasses constitute this group. Other and not related der- 
matoses have bullous phases, notably erythema exudativum bullosum 
(Chapter VI), urticaria bullosa (Chapter VII), impetigo conta- 
giosa (Chapter XXIV), variola and varicella (Chapter VI), lepra 
(Chapter XXV), and syphilis (Chapter XLII), and certain drug 
eruptions of both external and internal causation. The common 
feature of the group is the bulla, the characteristics of which have 
already been described (Chapter IV). These lesions again illus- 
trate the doctrine of skin reactions, as do wheals and vesicles, and 
in another day when the nature of dermatoses is better understood, 
so superficial an attribute as the appearance of a lesion will cease 
to suffice as a bond for associating maladies which are fundamentally 
unrelated. 

PEMPHIGUS 

Synonyms. Pompholyx, 1 German Blasenausschlag. 

Pemphigus is an acute or chronic bullous dermatosis occurring in 
several varieties, characterized by clinical or prognostic differences. 
Ormsby recognizes four types : pemphigus acutus, vulgaris, foliaceus, 
and vegetans. Finger recognizes benign pemphigus, or pemphigus 
vulgaris, and malignant pemphigus of which there are four types: 
the acute malignant, pruriginous, foliaceus, and vegetating. These 
two will serve as examples of the usual ways in which the disease is 
classified. For simplicity, Ormsby's makes the greatest appeal. 

PEMPHIGUS ACUTUS 

Also known as Acute Febrile Grave Pemphigus, or Acute Infec- 
tious Bullous Dermatitis. 

iThis term is obsolete as applied to pemphigus; it is commonly used as an 
abbreviation for cheiropompholyx. 

134 



BULLOUS DERMATOSES 135 

Definition. Acute pemphigus is apparently an infectious disease 
characterized by a prodromal period and an eruptive stage. It is 
usually fatal, or goes into a chronic form conforming to the vulgar, 
exfoliating, or vegetating types. In rare instances the disease is 
supposed to end in recovery. 

Symptoms. After an inaugural stage of malaise, chills and 
fever, an eruption of blebs appears. The lesions vary in number 
and size. There may be but few, or they may be numerous and 
widely disseminated, including the visible mucous membranes, and 
they may be as small as lentils or as large as an egg. At first, the 
contents are clear and serous; later they become cloudy and puru- 
lent, and when they rupture crusts form. At times the mucosa is 
spared; at times even the conjunctivae are involved, causing edema 
of the lids. Blebs in the mouth usually rupture promptly and their 
residue appears as a superficial gray lesion at times covered by a 
membrane. At times the blebs contain blood as well as serum. As 
a rule the lesions arise from inflamed skin, but occasionally a red 
halo surrounds their bases. The prostration is frequently severe, 
and high temperature, at times even hyperpyrexia has been noted. 

Course. The course varies. Beginning as an acute infectious 
disease, a bullous eruption develops. The duration of the malady 
may be from several days to a few weeks and it usually ends fatally. 
At times the disease merely represents the beginning of a chronic 
type. 

Varieties. There is a supposedly benign form, which, however, 
may not belong with this disease, but rather with pemphigus vulgaris. 

Differential Diagnosis. Only dermatitis herpetiformis, eryth- 
ema bullosum, urticaria bullosa, varicella and variola may be 
confused with this malady. Dermatitis herpetiformis never starts 
so suddenly, there are slight or no constitutional symptoms, the 
course is prolonged, and the lesions fairly characteristic. (See 
below.) Erythema bullosum is mild, and lesions characteristic of 
the erythema group are present. (Chapter VI.) The presence of 
wheals and factitious urticaria differentiate hives from pemphigus. 
Varicella is a disease of childhood and crops of papules as well as 
umbilicated blebs are present. Variola is the disease most likely to 
simulate acute pemphigus. Variola occurs in epidemics, as a rule 
is divided definitely into well-recognized stages (Chapter VI). 
the fever curve and double period of eruption, the umbilication of 
the blebs, should all render the diagnosis relatively simple. 

Etiology and Pathogenesis. Very little is known of the cause 



136 DERMATOLOGY 

of the disease. After wounds, in those engaged in handling dead 
animals, preeminently in butchers and anatomists, the syndrome 
appears so that there is a great possibility of its being due to infec- 
tion. It may possibly be related to foot and mouth disease as was 
suggested by Bowen twelve years ago. 

Treatment. Quinine and arsenic have been used. Sympto- 
matic, in want of rational, therapy is all that there is to offer. One 
is utterly helpless before the problem of treating pemphigus. 

Prognosis. The patients usually die. 

PEMPHIGUS VULGARIS (FIG. 17) 

Definition. This is a rare chronic eruption of bullae, few in 
number as a rule, extending over a period of months or years. 

Symptoms. After a period of slight malaise, or without 
prodromata, a few blebs (Fig. 17) arise which either dry, or break 
and crust. The lesions are tense or flaccid, contain serum, pus, or 
blood, or some combination of the three, always, however, at first 
serum alone. Successive crops of one or more blebs arise either just 
before, just after, or at a variably long interval after a given series has 
healed. Thus, at times there is a polymorphous picture, — blebs and 
crusts, the color determined by the contents, and pigmentation where 
the lesions were. There is no inflammatory zone about the bullae. 
On the visible mucosa and conjunctiva ruptured blebs with grayish 
bases are often to be observed. Accompanying the outbreaks, there 
may be a rise in temperature of from two to four degrees, and con- 
siderable prostration, decompensation of the heart, nephritis, enter- 
ocolitis, and a slight hyperleukocytosis and relative increase in 
the neutrophiles. 

Course. The disease may last for months or years, and end as 
an acute, grave, or as foliaceus, or vegetating pemphigus. Compara- 
tive health may persist for a long time before the more serious 
phases of the illness develop. 

Varieties. The varieties of this form of the disease are those of 
incidence, such as pemphigus solitarius when but one lesion recurs 
at a given site, or pemphigus diutinus, disseminatus, hemorrhagicus, 
or conjunctival or buccal pemphigus. Dr. Martin Cohen referred 
a case of pemphigus vulgaris of the conjunctiva and cornea to the 
Dermatological Clinic at the New York Post-Graduate Hospital. 
This patient, a middle aged widow, also had buccal lesions. Fabry 
in 1915 reported similar ocular lesions in pemphigus foliaceus. 

Differential Diagnosis. Because of the character of the lesions, 



BULLOUS DERMATOSES 137 

their non-inflamed base, the slow course of the disease, and the ab- 
sence of other signs of multiform erythema or urticaria (the only 
two conditions which might cause confusion) the diagnosis of 
pemphigus vulgaris is simple. 

Etiology and Pathogenesis. Actually, nothing is known of the 
cause of the disease. There are three theories as to its origin, 
infectious, toxic or metabolic. A series of micro-organisms has been 
described, the bacillus pyocyaneus, and several peculiar organisms 
reported by Lipchiitz in 1911 ad 1912. No confirmation exists. 
Johnston favors the metabolic view, and this appears reasonable but 
remains unproved. In an analysis of thirty cases, neither age, sex, 
occupation nor general health had any relation to the disease. 
Twenty-nine of the patients were Hebrews. No laboratory work 
threw any light on the etiology. Dr. Hermann Goldenberg, with 
whom I had the pleasure of collaborating, considers the disease in- 
fectious. 

Treatment. Arsenic is supposed to be of value, and in the case 
of conjunctival pemphigus noted above, appears to have been. On 
the basis of its being a toxic disease, colon irrigations are indicated, 
and tonic treatment should be used. The local therapy consists of 
employing dusting powders, Lassar's paste and diachylon ointment, 
and perhaps the permanent bath as it is employed in Vienna. 

Prognosis. All of the thirty cases mentioned above died. 
Among them were about a dozen patients with pemphigus vulgaris. 
The patients may survive for years, but they ultimately succumb to 
an incurrent infection, cachexia, or a general lighting up of the 
process. At times the condition evolves into pemphigus foliaceus 
or vegetans. A benign form is known which after weeks or months 
disappears. It is questionable whether this is really pemphigus 
for it is almost unanimously agreed that pemphigus is always fatal. 

PEMPHIGUS FOLIACEiUS (FIG. 18) 

Definition. Pemphigus foliaceus is a rare form of pemphigus in 
which the primitive lesions are flaccid bullae which appear in great 
numbers and lead to an almost universal exfoliation, so that the 
condition actually appears to consist of a mixture of blebs and large 
scales. 

Symptoms. The onset may be preceded by prodromata such as 
weakness, malaise, mild fever, one or two blebs (Fig. 17) on the body 
or in the mouth, or the disease may start suddenly as pemphigus 
acutus, or gradually with the clinical picture of dermatitis herpeti- 



138 DEEMATOLOGY 

forrais, or after pemphigus vulgaris. A patient with the disease in 
its tvpical aspect presents a fairly characteristic picture. The facies 
are anxious, and an impression of great suffering is imparted, due to 
the actual pain in the skin, the discomfort of the inflamed integu- 
ment, and the agony caused by friction of areas denuded of epi- 
dermis. Analysis of the lesions reveals several points. Isolated 
flaccid blebs of sudden evolution are present. These discharge their 
contents of seropurulent secretion which in drying forms fragile 
crusts. Below the latter, as well as below the blebs themselves, 
inflamed skin denuded of its epidermis is seen. This bleeds slightly. 
As the lesions are covered with ill-formed epithelium, new blebs de- 
velop below, lifting off the imperfect covering. Thus, large stratified 
scales and crusts are formed. Besides this, the epidermis easily peels 
off even without the presence of blebs. This is known as Nikohky's 
sign and is due to serous saturation of the epiderm, lifting the upper 
layers of the latter aloft. The scales thus formed dry rapidly and 
resemble pie crust (Fig. 18). The picture consists of two essential 
elements, bullae and scales. As the disease extends, the entire skin 
is involved, and it all appears to be exfoliating, the surface below 
being red, and at the margins of the scaling areas residual bullae 
are seen with their crusts and scales. The mouth, vulva and body 
folds are included, and moisture causes maceration. Fissures (Fig. 
18) form all over. The extremities swell, as do also the ears, which 
thus lose their normal contour, the eyelids grow puffy, purulent con- 
junctivitis often develops, the nails become distorted and may even 
fall, while the hair usually falls out also. In the course of time 
palpebral ectropion develops, and at points of pressure decubiti may 
arise. An odor suggesting the charnel house is common in pem- 
phigus foliaceus. 

Fever accompanies the picture, but at times when the patient ap- 
pears well it is as high as 103 or 101, while during periods of 
extension it may be normal. There is no relation between the fever 
and eruption, nor is there anything typical about the curve. It is 
purely capricious and simulates neither the fever of typhoid, malaria 
nor sepsis. Bodily function may be undisturbed for prolonged 
periods, but diarrhoea commonly is present, and the evacuations are 
often foul and contain mucous. Vomiting, too, is not rare and 
renal involvement may also be seen. Bestlessness is common and 
periods of mental flightiness are not infrequent. In a case I had 
the opportunity to observe closely the patient at first appeared well, 
the appetite was good and the intestinal function regular. AJiter 



BULLOUS DEKMATOSES 139 

ten weeks the stools became clay-colored, these alternating with foul 
green evacuations. Two weeks later the feet became edematous, 
and a day or two after this albumin and hyalogranular casts were 
found in the urine. In a fortnight more there was glycosuria which 
lasted for two days; then, suddenly for no reason, the albumin and 
casts disappeared and the diarrhoea became controlled by the use 
of paregoric. Preceding this chain of developments the afternoon 
temperature had been between 101 and 102; as the disease grew 
severer the temperature became and remained normal. The pulse 
in pemphigus foliaceus is weak and rapid, about one hundred and 
twenty, the respirations about twenty-six and the leukocyte count 
about ten thousand, but the relative proportion of the various white 
blood cells remains unchanged. 

Course. The disease lasts for weeks or months, exceptionally for 
years. Exhaustion, intractable enterocolitis, or an intercurrent in- 
fection, often pneumonia, sometimes sepsis, ends the patient's agony. 

Differential Diagnosis. The presence of blebs, exfoliation, and 
Nikolsky's sign characterizes the disease. Dermatitis exfoliativa 
(Chapter XII) may remotely simulate it, but the points above 
enumerated should prevent error. 

Etiology and Pathogenesis. It is valueless to speculate on the 
probable cause of the malady. It is obviously either toxic, metab- 
olic or infectious in origin, but there are insufficient data to justify 
belief in one possibility to the exclusion of the others. The bacillus 
pyocyaneus has been regarded by Hazen as the cause in some cases. 

Treatment. The treatment is similar to that of pemphigus vul- 
garis and quite as expectant and futile. 

Prognosis. Death is inevitable, usually no later than within two 
years of the onset. 

PEMPHIGUS VEGETANS 

Synonyms. Pemphigoides Maligna, Herpes Vegetans, Condy- 
lomatosis, Erythema Bullosum Vegetans. 

Definition. Pemphigus vegetans is a rare (about seventy cases 
on record) malignant illness, characterized by the formation of 
bullae from the bases of which spring vegetations which become 
condylomatous. 

Symptoms. The disease begins in one of two ways. Either 
there are prodromata such as malaise, languor and mild fever fol- 
lowed by bullae in the visible mucosa of the body orifices, or the 
early stages of the condition simulate pemphigus vulgaris, or derma- 



140 DEKMATOLOGY 

titis herpetiformis. In any event the eruption soon limits itself to 
the mucosa at the sites mentioned, the axillae, elbow flexures, groins, 
base of neck, umbilicus and the cutaneous areas immediately adja- 
cent. Any or all of the sites enumerated may be involved simulta- 
neously.. Most frequently, however, the process is for a long time 
restricted to the mouth, anus, or vulva. The lesions themselves are 
at first bullae of various sizes, and are numerous and close-set, or 
sparse. They are either tense, containing serous fluid, or flaccid, 
containing pus. They soon rupture and on mucous surfaces are 
covered with a dirty gray membrane, while on the skin they are 
crusted. Underneath the membrane or crusts arise papillomatous 
or condylomatous vegetations, surrounded by a red zone, and in this 
stage the flat, macerated, vegetating papules of syphilis, called condy- 
lomata lata, are closely simulated. An overpowering fetor is exhaled 
from the mouth, and the lesions elsewhere have an equally revolting 
odor. The nails and hair may fall out. 

Course. The progress is one of alternate periods of remission 
and recrudescence, with each accession severer than its predecessor, 
until after months or years the patient succumbs to asthenia, inter- 
current infection, or to the severity of the illness itself. There is 
no regular fever curve characteristic of the disease, although more 
or less increase in temperature at times exists without, however, in 
any way running parallel to the severity of the illness. Occasionally, 
periods of vomiting, diarrhoea, coughing and the like arise, and do 
not seem to bear any direct relation to the disease. 

Varieties. There are no true varieties of the disease other than 
those due to accidents of site, severity, intensity, and height of the 
fever, save that there are two ill-conceived groups of cases, the malig- 
nant and benign. The former is true vegetating pemphigus; the 
latter is not pemphigus at all, but probably vegetating dermatitis 
herpetiformis. 1 

Differential Diagnosis. Only syphilis simulates this malady, 

i This distinction will hold good as long as we differentiate between pemphigus 
and Duhring's disease. Evidence is accumulating, however, that there is no 
great difference between the two diseases. The description of pemphigus given in 
the text reflects the accepted views. In an analysis of thirty cases studied by 
Dr. Goldenberg and me in the wards of the Mt. Sinai Hospital we found 
that the disease was always fatal, nearly always began in the mouth, and that 
pemphigus vulgaris always preceded the foliaceous and vegetating variety. We 
thus regarded the described types as clinical variants of a single disease, and 
we gained the impression that its causation was more likely infectious than 
anything else. Cases simulating pemphigus that recover are not pemphigus. 
Hence in this sense dermatitis herpetiformis and pemphigus may be divorced. 



BULLOUS DERMATOSES 141 

and actually it is the lesions alone of which this is true, not the entire 
process. The benign nature of syphilis, other characteristic lesions 
thereof, the positive Wassermann test, the presence of spirochaetae 
in syphilitic condylomas, the absence of blebs as well as other signs 
of pemphigus eliminate confusion. 

Etiology and Pathogenesis. Nothing is known of the causa- 
tion of the malady. The long array of alleged causative micro- 
organisms, the numerous conventional explanations of the condi- 
tion, amply indicate the incorrectness of any. 

Treatment. There is no rational therapy. It is possible only 
to confine our efforts toward increasing the comfort of the patient and 
maintaining asepsis as to the parts affected, along the lines laid 
down in pemphigus vulgaris. 

Prognosis. The disease is fatal. 

DERMATITIS HERPETIFORMIS (FIG. 19) 

Synonyms. There are numerous other names for this disease. 
It is important however to remember only Herpes Gestationis, Duhr- 
ing's Disease, and the French term, Dermatite Polymorphe 
et Douloureuse. 

Definition. The disease is uncommon, if not actually rare, and 
is characterized by an eruption of vesicles, blebs, pustules and 
papules which appear in several crops, variable grouping, and in- 
constant distribution. They are attended by burning, pain or itch- 
ing of variable intensity. Occasionally, malaise or slightly more 
marked systemic disturbances, even low fever accompany the picture. 
From this the French term, painful and polymorphous dermatitis, 
appears the most aptly descriptive. 

Symptoms. The onset of the disease may lack constitutional 
symptoms, but more often is characterized by malaise, chills, chilli- 
ness, fever, and at times rigors followed by itching, burning, or 
pain. Within a day or two a polymorphous (Fig. 19) exanthem ap- 
pears consisting of macules, papules, tubercles, vesicles or blebs, 
either on the skin alone (Fig. 19), the mucosa or both. The possible 
combinations and number of these lesions are boundless, and they may 
be restricted, universal, disseminated, discrete, coalescent, or grouped 
in a manner suggestive of herpes. Features of multiform erythema, 
pemphigus and acute vesicular dermatitis are simulated. In long 
standing cases the extensor surfaces of the limbs, the sacral, tro- 
chanteric areas, and shoulders are involved. As one crop involutes 
others arise, and new lesions tend to group themselves about the 



142 DERMATOLOGY 

remains of the old so that festooned, circinate and gyrate areas de- 
velop, consisting of one or more of the component types of lesions. 
When the mucosa is involved the lesions are indistinguishable from 
those of pemphigus. This is also often true of the skin. The bul- 
lous lesions dry and form crusts and occasionally become purulent, in 
which case the crusts assume the characteristics of dried pus. In ad- 
dition to this the papular lesions may be scratched open, and there- 
fore the picture is further complicated by the presence of excoriations. 
Areas of lichenification too may develop (Chapter XIII). Al- 
though the process itself causes no scarring, at times deep scratching 
and local infection may leave superficial scars which not rarely are 
pigmented or depigmented. 

Course. The illness may last for months or years and is note- 
worthy for its varying periods of activity, partial or complete quies- 
cence. Although usually it does not shorten life, occasionally ma- 
lignant forms end fatally, simulating either variola, or exfoliative 
dermatitis. Such cases are indistinguishable from malignant pem- 
phigus vulgaris, or pemphigus foliaceus. 

Varieties. A form of this disease seen during pregnancy is known as 
herpes gestationis. Another variety, impetigo herpetiformis, also almost 
entirely restricted to this class of patients, is very severe. It is charac- 
terized by an exanthem of pinhead pustules with yellow or green contents, 
and an inflammatory base. The buccal mucosa is also involved, and half 
of the patients die. A few cases have been observed in men. 

Differential Diagnosis. To differentiate this from pemphigus 
is almost impossible. Only observation of the patient throughout 
his life can lead to a positive conclusion. It is known that many 
cases of pemphigus begin as dermatitis herpetiformis, and that many 
cases of dematitis herpetiformis end with the clinical aspect of any 
form of pemphigus. Only the polymorphous attributes of Duhring's 
disease indicate the possibility of its being a clinical entity, and I 
am not convinced that this alone is sufficient to separate it from 
pemphigus, nor has the Viennese school ever accepted the distinction. 
Although the terminal stages of malignant dermatitis herpetiformis 
simulate variola, the case history makes confusion impossible. Sim- 
ple dermatitis resembles dermatitis herpetiformis only as to certain 
lesions, but the picture in its entirety is quite different, unless 
lichenification arises. Then chronic dermatitis (eczema) is 
mimicked, but only remotely. Bullous multiform erythema is 
sometimes hard to differentiate from dermatitis herpetiformis, but 



BULLOUS DEKMATOSES 143 

the typical lesions of the former interspersed among the bullae 
should indicate, if not actually determine, the correct diagnosis. 

Etiology and Pathogenesis. No one explanation has yet been 
accepted to account for the disease. Johnston and Schwartz have 
found nitrogen retention preceding outbreaks in chronic cases. 
The usual sophisms concerning reflex neuroses and the like still 
have their advocates, as is always the case when the etiology of a 
disease is unknown. Herpes gestationis may be due to pregnancy, 
but there is no proof of it yet, and it is more likely simply to be 
dermatitis herpetiformis coincident with pregnancy. Although 
still unproven, impetigo herpetiformis is evidently a systemic infec- 
tion. The cases are rare and blood cultures have not yet been done, 
but the behavior of the patients suggests the probability of sepsis 
with pyoderma probably due to bacterial embolism. 

Treatment. Arsenic is the only efficacious drug in this illness 
and more recently it has been the experience of all that cacodylates 
have been the most useful. Injections should be given every other 
day starting with one or two grains and increasing the quantity to 
the point of tolerance. Salicylates and thyroid extract have been 
praised by some. Johnston forbids excessive proteid diet in cases 
with nitrogen retention. The local treatment corresponds with that 
of pemphigus. In impetigo herpetiformis induction of labor is 
indicated, and symptomatic local therapy, as in pemphigus. 

Prognosis. In dermatitis herpetiformis, and excepting in ma- 
lignant cases, or in those cases which evolve into pemphigus, the prog- 
nosis as to life is good, and as to a permanent cure almost uniformly 
bad. About half of all of the cases, either correctly or incorrectly 
regarded as dermatitis herpetiformis, die. It is probable, however, 
that those ending fatally do not belong in this group, but are pem- 
phigus. 

HYDEOA VACCINIFORME 

This disease is also known as recurrent summer eruption, or herpes 
aestivalis. It is a vesicular disease restricted almost entirely to boys and 
the lesions appear on exposed surfaces (hands, face, and forearms) every 
summer. Either one or more crops come with the hot weather, and the 
characteristic lesions are vesicles or small bullae which break, crust, and 
leave depressed pigmented or non-pigmented scars. With adolescence the 
disease ends. It is due to the effect of actinic rays on a skin, either sensi- 
tized to their action, or lacking some protective elements which make 
normal skin resistant. There is no cure for the condition during child- 
hood, but spontaneously at adolescence the attacks cease. 



144 DERMATOLOGY 

EPIDERMOLYSIS BULLOSA HEREDITARIA 

This is a rare hereditary and familial disease characterized by the forma- 
tion of bullae which arise as the result of the slightest trauma. The 
bullae are flaccid, rupture easily, and leave depressed scars. Gradually, 
the entire body may be covered. The general health remains unaffected by 
the disease, although there is no cure known for it. It is hereditary and 
due to a malformation of the elastic tissue. Usually, the first signs of the 
malady appear shortly after birth, at times, however, later in life. Wise has 
recently described epidermolysis bullosa acquisita appearing in adults and 
resembling the hereditary form clinically, but not etiologically. 





Fig. 17. PEMPHIGUS VULGARIS 

Unruptured bullae, without inflammatory base, appear near the 
groin. A ruptured one is seen below the left knee. Here and there 
are seen healing, crusted and healed lesions, and hyperpigmentation. 
Other conditions suggested are dermatitis herpetiformis, bullous 
urticaria, bullous erythema multiforme, and bullous bromoderma, all 
excluded by the nature of the blebs near the groin. 




Fig. 18. PEMPHIGUS FOLIACEUS 

In this type of pemphigus, the entire skin peels in large flakes. The integument 
is red and tender, and exfoliation results from large, flat, flaccid blebs. Dermatitis 
exfoliativa of the Hebra and Wilson-Brocq type differ in the absence of blebs, mu- 
cous involvement and greater thickening of the skin. 




Fig. 19. DEKMATITIS HERPETIFORMIS 

This rare disease is also named for Duhring, and called polymorphous and pain- 
ful dermatitis in France, a most descriptive term. There is grouping of vesicles, 
as over the left arm and shoulder, and bullae and papules appear as between the 
scapulae. Crusting, scaling, festooned margins, patches, excoriations, and lesions in 
all phases of development and disappearance are encountered. A certain relation- 
ship to pemphigus is admitted. Itching, burning and pain are subjective features. 



GKOUP III. CUTANEOUS REACTIONS CHARACTER- 
IZED BY SCALING OR LICHENIFICATION 

Three classes of dermatoses constitute this group — the psoriasi- 
form, erythrodermal and lichenous. They are all clinically char- 
acterized by scaling, the majority without any deep seated infiltra- 
tion, some, however, having this attribute. The psoriasiform 
diseases are macular or maculo-papular, the macules often coalescing 
into placques in psoriasis itself, and sometimes in seborrhoea. The 
erythrodermas are usually diffuse. The lichens are infiltrated 
papules, and lichenification is a primary or consecutive infiltrating 
process. 

CHAPTER XI 

PSORIASIS AND THE PSORIASIFORM DERMATOSES 

There are four grand classes of psoriasiform dermatoses ; psoriasis, 
seborrhoea, parapsoriasis, and pityriasis rosea. Of these, only 
psoriasis is a clean-cut entity, standing by itself in the center of 
the group. Although perhaps premature at this point, it must be 
stated that parapsoriasis unites the scaling dermatoses with gran- 
uloma fungoides (Chapter XXVI), pityriasis rosea forms a link 
with exudative multiform erythema and the toxic dermatoses 
(Chapter VI), and seborrhoea is the starting point of numerous 
forms of simple dermatitis (Chapter IX), notably those classed as 
eczema. 

psoriasis (pig. 20) 

Synonyms. Lepra alba, psora, alphos ; German, Schuppenflechte. 

Definition. Psoriasis is a scaling dermatosis, inflammatory in 
nature, usually chronic in course, more frequently gradual than 
sudden in onset, and characterized primarily by a red papule sur- 
mounted by white scales. 

Symptoms. As a rule, psoriasis makes its appearance in the 
second or third decade of life. It also frequently begins late in 
adult life, and rarely in infancy.* Although it may start with a 
sudden diffuse and generalized eruption, the vast majority of cases 

145 



146 DERMATOLOGY 

begin gradually with the appearance of roseate, just perceptible 
papules, surmounted by a white, silvery, or nacreous imbricated 
scale (Fig. 20). These papules increase in size and number. The 
larger the papule, the deeper its color, so that there is a wide range of 
hues varying from barely recognizable pink to deep purplish or 
brownish red. The scales are usually not firmly adherent, but may 
be. More often it is easy to scrape them off with the finger nail. A 
bare, inflammatory zone surrounds the scale (Fig. 20), and the entire 
lesion is sharply demarcated from the normal skin. The lesion is 
infiltrated, and the older ones are distinctly raised, sometimes an 
eighth of an inch. They are impliable and somewhat harder than 
normal integument; in fact, frequently leathery (Fig. 21). At 
times the scales, particularly in older lesions, are yellowish or gray. 
Upon their removal, bleeding puncta appear which correspond to en- 
gorged papillae, and which are almost pathognomonic. 

The sites affected are various. On the whole, the extensor sur- 
faces are more profusely involved than the flexors, and in these 
forms which exhibit but few lesions, there seems to be a preference 
for the scalp, joints of the elbows and knees. Thus, both extreme 
limitation and wide distribution of the lesions are known. The 
sites rarely involved are the palms and soles, while the lips and other 
orificial mucosa never are. 

A limitless series of aspects is a feature of the disease. It may 
consist of widely disseminated (Fig. 20), small, pale lesions, or 
such lesions in only certain areas. Or the spots may be larger, even 
veritable plaques (Fig. 21), all over or just on the favored areas; or, 
there may be a mixture of the types. This has caused the creation of 
a series of terms purely descriptive of accidents of size, shape and 
arrangement of the component elements; as psoriasis punctata (Fig. 
20), when the lesions are tiny (Fig. 20) ; guttata, when they are the 
size of a drop of liquid; nummularis or discoidea (Fig. 21), when 
coin-sized; circinata or orbicularis, when they enlarge peripherally 
and heal centrally; figurata or gyrata, when the circinate lesions 
coalesce forming festoons; geographica, when the lesions simulate 
maps ; diffusa, when large areas of the skin are involved ; rupioides or 
ostracea, when the scales are thick and resemble oyster shells ; follicu- 
laris, when about follicular openings ; and inveterata, when persistent, 
thickened, or fissured. Of course, this is all purely artificial. 
There are also psoriasis acuta, chronica, pruriginosa, capitis, 
et cetera. 

As a rule, itching is absent, but in some cases may be intense. 



PSORIASIS AND THE PSORIASIFORM DERMATOSES 147 

The general health usually remains good, and there are no chemical 
or biological alterations which are diagnostically characteristic of 
the disease, as the Wassermann reaction is characteristic of syphilis, 
or the blood picture of leucemia. 

Although the scalp (Fig. 20) is a favorite locality for psoriasis 
lesions, the hair rarely falls. The scales on the scalp are generally 
powdery or crusted, and often the lesions are numerous. The nails 
are affected in one of two ways ; either the papule develops under the 
nail raising it, or it arises in the nail bed, and as the nail grows it 
is distorted, being indented with minute pin-point depressions such 
as might be produced by puncturing paper with a fine point. The 
nails are often brittle, dull, or misshapen because of the involvement 
of the matrix during the developmental period. 

For the sake of emphasis, certain features of the psoriasis papule 
will be recapitulated. It is dry, scaling, never weeps and rarely 
itches. Upon the removal of the scale hemorrhagic dots are seen, 
sometimes so minute as to require magnification to detect their 
presence. 

Course. Psoriasis usually begins between the eighth and twen- 
tieth year of life, often later, almost never earlier, and is capable 
of following one of several courses. It may start suddenly with a 
widely disseminated papular rash, or insidiously with a few spots 
which enlarge and increase in number. There may be periods of re- 
mission during which the patient is apparently free for months or 
years, but close examination will usually reveal a few lesions some- 
where — either on the elbows, knees or scalp. At the onset the 
lesions may be punctate or guttate, and later assume any of the 
aspects already mentioned. After the period of chronicity has set 
in, the lesions may persist indefinitely in any form and neither ad- 
vance nor recede. The process is unattended by grave complica- 
tions or sequelae, but in rare instances epitheliomata are said to 
have arisen from inveterate patches, particularly in patients who 
have received arsenic. Superpigmentation or depigmentation also 
are known, and this, too, may be connected with arsenic therapy. 

Varieties. There are no varieties save those due to accidents of 
appearance, localization and course. Rarely, the lesions may be- 
come verrucodd. 

Differential Diagnosis. Psoriasis is more or less closely sim- 
ulated by syphilis, pityriasis rosea, parapsoriasis and seborrhoea, the 
exfoliating erythrodermas and premycosis, and remotely by pityriasis 
rubra pilaris, lichen planus, lichen simplex and ringworm. 



148 DEKMATOLOGY 

Disseminated psoriasis resembles papular syphilis in the secon- 
dary stage. The psoriasis papule has definite attributes which that 
of syphilis lacks. The scale of the latter is not imbricated and 
silvery, but consists of a single layer, nor does its removal cause 
any punctate hemorrhages. 1 In syphilis, in this stage, other factors 
exist which are lacking in psoriasis, such as mucous patches, flat 
condylomas, glandular enlargement, and the positive Wassermann 
test, as well as constitutional symptoms. Syphilis, also, is prone 
to involve the palms and soles, and favors the flexor surfaces in gen- 
eral, while the hair often falls out. 

Old plaques of psoriasis which are festooned, gyrate or circinate 
in character must be distinguished from similarly arranged forms 
of tertiary syphilis, chiefly tubero-serpigenous gummata. The color 
of psoriasis is more vivid, that of syphilis brownish or buff. Psoria- 
sis scales are white, those of the late syphiloderm gray or muddy and 
almost crust-like. The consistency of the psoriasis lesion is leathery, 
that of the luetic lesion more distinctly a deep infiltration. Other 
evidences of syphilis may be present, particularly the serum reac- 
tion, and these serve to clear up the question. Instances in which 
confusion might arise in differentiating palmar or plantar psoriasis 
from squamous syphilis at these sites are infrequent, since psoriasis 
here is rare and syphilis common; the Wassermann reaction is 
absent in the former and likely to be present in the latter, and finally, 
the therapeutic test in syphilis by the use of salvarsan or mercury 
should establish the correct diagnosis. 

Pityriasis rosea, parapsoriasis and seborrhoea will be discussed 
later in this chapter, and the points of differentiation will then be 
enumerated. Universal psoriasis may closely resemble the exfolia- 
tive erythrodermas, and the so-called premycotic dermatoses. In- 
deed, the most expert are at times at a loss to find points of differ- 
entiation, and only close study of the cases will lead to correct inter- 
pretation. In general, it may be stated that universal psoria- 
sis runs a milder course as to general symptoms than do the erythro- 
dermas. Psoriasis, finally, involutes at least partly, while the ery- 
throdermas, although punctuated by remissions, grows progressively 
worse, the patient's general health deteriorating, while gradual wast- 
ing leads to death. It is hardly fair, however, to await a fatal issue 
in order to make a diagnosis, and the only points upon which to base 
an opinion of psoriasis would be the facts that somewhere on the body 

i It is inadvisable to scratch syphilis papules with the finger nails, because of 
the danger of infection. 



PSORIASIS AND THE PSORIASIFORM DERMATOSES 149 

a few characteristic lesions of this disease might be demonstrable, 
the absence of general glandular enlargements such as are seen in 
many of the erythrodermas, and finally the pervading impression of 
good health. 

Lichen acuminatus and lichen planus resemble psoriasis only when 
they are in the forms of coalescent patches. There is more infiltra- 
tion than in psoriasis, more pruritus, and the color of lichen acumin- 
atus is a rather more decided buff, while that of lichen planus is 
violet or purple. The scales are more adherent in the lichens, not 
silvery, and their removal does not occasion punctate hemorrhages. 
In lichen planus, too, there is often mucous involvement, which in 
psoriasis is wholly unknown, while in psoriasis the scalp and face 
are involved which never occurs in lichen planus. Finally, typical 
lesions of the various maladies clear up the diagnosis. (Chapter 
XIII.) Lichen simple chronicus, or the neurodermite of the 
French, also known as eczema papulosum or lichenification, for the 
most part favors the flexor surfaces, notably those of the knees and 
elbows, the small of the back and nape of the neck. Particularly the 
first two sites are rarely affected in psoriasis, while the scalp is 
affected by this disease, and practically never by any form of lichen- 
ification. The patches of lichenification are thickened, circum- 
scribed, furrowed by transecting lines, red, buff, or violet in color, 
and outside of their periphery are minute, red, lenticular papules. 
Often, too, lichenification is associated with some other disease such 
as dermatitis, dermatitis herpetiformis, scabies, prurigo, and the like. 
Several forms of ringworm resemble psoriasis. Here the diagnosis 
must depend upon a demonstration of the fungus. 

Etiology and Pathogenesis. Psoriasis is equally common in 
both sexes, in all social classes regardless of occupation and race, save 
that it is unusual in negroes. It rarely occurs before ten or after 
forty-five. Heredity, in the loose manner in which this factor has 
been conceived in medicine, has been held responsible. Knowles, 
however, found but six familial cases in hundreds which he studied 
and decided against heredity, a view with which I emphatically 
agree. A disease observed in four percent, of all patients with 
dermatoses must occasionally appear in several members of a family, 
and there is no more proof of the heredity of psoriasis than of colds 
in the head, in fact less, since colds are almost universal. 

Pollitzer in a brilliant analysis of the subject favors the idea of 
infectious origin. There is no proof of this and all reasoning is 
purely by analogy. On the other hand, there is perhaps no con- 



150 DERMATOLOGY 

vincing opposite evidence. Rheumatism and gout have been widely 
regarded as the cause in this country, and particularly in England. 
In the first place, there is no uniformity in our knowledge of these 
two diseases. They are not alike, and both are so common that it 
would be astonishing if they were not occasionally associated with so 
ordinary an illness as psoriasis. Xor is there any logical evidence 
of a nervous origin. It is not a cutaneous neurosis, nor is it a 
trophoneurosis, for it has never been found coupled with lesions in 
the central nervous system. A certain suspicion exists, however, 
that it may be due to disturbed nitrogen metabolism, although the 
work of Johnston and Schwartz is against this. They made nitrogen 
estimations on urine in various stages of the disease and found no 
variation from the normal. On the other hand, a most exhaustive 
and pretentious study of the subject by S chamber g indicates an ab- 
normal nitrogen retention. There is no direct evidence either that 
disturbances of the endochrinous glands are at fault, although the 
occasional instances of improvement following the use of thyroid 
point to the possibility of hypothyroidism, at least in selected cases. 

It is a matter of common knowledge that involution and recru- 
descences occur in the disease without apparent rhyme or reason. 
Thus some patients are better or worse during given seasons ; women 
may improve or get worse during parturition, lactation, or the 
menses; a change in diet appears to affect one group of patients 
favorably and not another, et cetera. From this, one must inevitably 
conclude that the oscillations in the course of the malady depend 
upon periodic and transitory changes in the body, or in the last 
analysis, that the disease is due to a disturbance in metabolism. 
Even if it should ever be shown that the cause is a specific micro- 
organism, the facts just enumerated would still remain important in 
their causal relation to the process as shifting influences determining 
the fertility of the soil to the infection. Such an infection might 
be local or general. The latter view may be excluded because there 
are no evidences of a systemic infection as we to-day understand the 
interactivity of pathogenic agents and their hosts. After all, lepra 
and syphilis act differently, nor is there any evidence of a local in- 
fective agent in psoriasis, nor are there any serologic studies which 
serve to illuminate this point. 

Cases present themselves with all kinds of associated diseases or 
conditions, as constipation, colitis, bronchitis, tuberculosis, malaria, 
syphilis, neurasthenia and many others ; but it is rare to find one in 
which the psoriasis and general disturbance coexist in a manner which 



PSORIASIS AND THE PSORIASIFORM DERMATOSES 151 

to any reasonable being would suggest cause and effect. And yet 
there is no doubt that controlling a general disturbance often seems to 
ameliorate an associated psoriasis. The improvement, however, it 
must always be remembered, may simply be due to one of the curious 
remissions so characteristic of the condition, and neither to internal 
therapy nor to improvement as to the general existing disease. 
There is no dermatosis in which post hoc ergo propter hoc reasoning 
is less apt and more fraught with danger. In short, no definite views 
may exist as to its etiology for all such views must inevitably be born 
rather of faith than fact. 

Treatment. The treatment of psoriasis must be considered un- 
der two heads, general and local. General treatment consists of diet 
and the internal administration of certain drugs, the choice of which 
will be determined by such indications as may appear to bear a 
causal relation to the disease. On the assumption that an excessive 
ingestion of nitrogenous food, or nitrogen retention, causes the con- 
dition, or some of its forms, it has become popular to restrict or 
entirely eliminate the proteid intake, including meats, fish, eggs, and 
vegetables high in nitrogen content such as beans, peas, lentils and 
the like. It has never seemed entirely rational to me to do this, as I 
know of no instances in which improvement on such diet has been 
occasioned in such a manner that it could not be explained either by 
efficacious local therapy, or a spontaneous remission. Such treat- 
ment, too, would be indicated if gout were present. Bulkley's rice 
diet represents an extreme in the application of these principles, 
justification of which has never seemed valid in view of results ob- 
tained.. So rigorous a limitation of food causes symptoms of starva- 
tion, and one instance has come to my notice in which an over-rich 
carbohydrate diet rapidly made the patient's skin worse, and caused 
a carbohydrate fermentation and mucous colitis. When the patient 
was put upon a bland, mixed diet all of her general symptoms, as 
well as her extensive and infiltrated psoriasis vanished (the latter 
within a fortnight), although the only local remedy employed was 
vaselin to keep the skin pliable. Should the patient have chronic 
nephritis, of course the diet and elimination should be the cardinal 
factors in deciding upon the mode of therapy. 

Various medicaments are employed, the favored of which are 
arsenic, the salicylates, colchicum and thyroid extract. Of these, 
only arsenic is very important. This substance is used orally or by 
injection. When administered by mouth the forms of choice are 
Fowler's solution, Asiatic pills or arsenic trioxide. The first is 



152 DERMATOLOGY 

given in the conventional manner, in increasing doses, or sodium 
arsenite may be selected. Arsenic trioxide is given in doses of 
0.0016 to 0.0033, three times a day after meals in pills. Asiatic 
pills are a favorite preparation once popular in Vienna, and very 
good. 

IJ Acid arsenosi 0.75 

Pulv. pip. nigrae 6.00 

Gum. accaciae . .■ 1.50 

Pulv. altheae rad 2.00 

Aquae qs 

M. Div. in pill No. C. 

Roughly each pill contains of arsenious acid Gr. % (0.0075). One 
pill should be given after each meal and the daily number increased 
by one until the patient reaches the point of tolerance. Jadassohn 
taught that arsenic alone would cure psoriasis, provided the patient 
were able to stand the required quantity, which might be extreme. 
Although there is no doubt that the substance is valuable, I am un- 
willing to take so optimistic an attitude regarding its utility. Sod- 
ium cacodylate is also useful and should be injected daily in in- 
creasing doses, beginning with one grain and stopping at the point 
of toleration. Symptoms of arsenical poisoning should be closely 
watched for and the drug stopped upon their appearance. The possi- 
bility of hyperpigmentation, hyperkeratosis and epithelioma should 
never be forgotten when arsenic is employed. Arsphenamin and 
atoxyl are useless. 

The salicylates and colchicum are employed in rheumatic and 
gouty subjects with psoriasis. I am not sure that their use is reason- 
able, although no harm can arise from it. Within the last few years 
Gottheil has advised autoserum in this malady. He stands prac- 
tically alone in his enthusiasm. Other investigators, notably Trim- 
ble, deny its value, and Bavitch and Howard Fox recanted in later 
papers enthusiasm expressed in earlier ones. At present the chief 
claim of Gottheil is that autoserum enhances the efficacy of chrysar- 
obin. Ringer's solution and normal salt solution have been admin- 
istered intravenously without benefit. Thus the only internal ther- 
apy having approximately universal approval is the employment of 
arsenic. 

Local therapy consists of the use of medicaments capable of re- 
moving scales and infiltrations by producing a more or less severe 
dermatitis. Such substances are known as revulsives and keratolv- 
tics and those which are of greatest efficacy are chrysarobin and some 



PSOKIASIS AND THE PSORIASIFORM DERMATOSES 153 

of its derivatives, pyrogallol and some of its derivatives, salicylic 
acid, certain alkalies, sulphur, resorcin and the tars. Ammoniated 
mercury is also of great value and radiotherapy has a wide field of 
utility. The choice of substances and the form in which they are to 
be dispensed is determined by the extent, size, depth of infiltration 
and site of the lesions. 

Before describing the methods of applying the materials enumer- 
ated their various general characteristics and modes of use must be 
outlined. Chrysarobin is an irritant, particularly in the presence 
of water. It is as bad in acute psoriasis as it is good in chronic, 
whether the latter be extensive or limited. It cannot be used upon 
the hands, face, or scalp, partly because it stains the skin brown 
and partly because, when brought in contact with the eyes, there is 
danger of exciting marked cunjunctivitis. It rapidly removes the 
eruption, leaving at the site of the papule a white stain rimmed by a 
chocolate colored margin. Neorobin is a chrysarobin derivative dis- 
covered by Schamberg who finds it more efficacious and less irritating 
than other similar substance. Pyrogallic acid is toxic, sometimes 
causing hematuria, or even fatal nephritis when employed over ex- 
tensive surfaces. Thus, its value is confined to the treatment of 
small areas. Salicylic acid is particularly good in cases in which 
the scales are especially thick, as are also alkalies, the most useful 
of which is potassium hydroxide as incorporated in green soap. 
Sulphur and resorcin have a limited sphere of utility, at times hasten- 
ing the involution of given lesions. Tar, particularly birch tar, oil 
of cade and pix liquida, of which the first is the best, are widely 
recommended. More recently carboneol (really technical coal tar) 
has come into use. The odor of these preparations is unpleasant 
and the tars and chrysarobin have the disadvantage of spoiling 
clothes. When applied universally in ointments dermatitis may be 
caused and even severe nephritis has been known to occur. It is 
safe, however, to employ it as did the Viennese a generation ago. 
Their method which was both pleasant and efficacious will be subse- 
quently described. When tar works it has several advantages over 
chrysarobin, the most important being that it does not discolor the 
skin. 

The precise methods of using the medicaments above outlined are 
as follows : 

Chrysarobin. After a warm bath a five percent, ointment should 
be rubbed into the skin vigorously. Lanolin, or equal parts of this 
substance and vaselin, make a good base. This concentration may 



154 DERMATOLOGY 

be too weak in some cases and double or triple the strength may be 
required. Instances frequently arise in which even thirty or forty 
percent, salves are required, but this is exceptional and dangerous 
because of the possibility of general poisoning. Nor, as has been 
mentioned, should chrysarobin ever be used in acute forms, but only 
in the chronic, whether disseminated or localized, and whether the 
lesions are small or large. For localized patches the drug may be 
incorporated in flexible collodion or traumaticin, and painted on with 
a small, soft brush or cotton applicator. It is wisest to remove the 
scales first by washing with soap and water. In inveterate patches 
it is found useful to rub in the salve vigorously for ten or fifteen 
minutes with the blunt end of a clothes pin covered with chamois. 
At times the chrysarobin may be fortified with two or three percent, 
of salicylic acid. Neorobin is best used as a salve, or in any other 
manner in which chrysarobin is employed. It seems quite as effi- 
cacious as the latter and less irritating. 

Pyrogallol. Except in isolated inveterate patches, this substance 
should not be used. When indicated, it is to be prescribed in ten 
percent, salves with any suitable base, and rubbed in vigorously once 
a day. In extensive cases eugallol (ten percent.) in acetone should 
be painted on once a day, after a hot soap bath. This substance does 
not stain the skin or clothes, dries almost as soon as applied, and 
often causes rapid involution of the lesions. It does discolor tiles 
and enamel, so that the patient should be cautioned not to spill it, I 
have seen it produce dermatitis only once. 

Resorcin and Sulphur are valuable in psoriasis of the scalp. They 
should be prescribed in ointments, resorcin in two to five percent, 
strength and sulphur in from five to ten percent. An application 
should be made once a day, and the patient instructed to shampoo 
once or twice a week. Although in general tincture of green soap 
is one of the worst things on earth for the skin, it is valuable in 
psoriasis because it softens the scales. On non-hairy parts of the 
body sulphur is often employed, particularly incorporated in Wilkin- 
son's ointment. 

I£ Flor. sulphuris 

01. Rusci aa 10. 

Sapon. virid. 

Adipis aa 20. 

Cretae alb 2.25 

Sig. 

This preparation should be rubbed thoroughly into the affected 



PSOEIASIS AND THE PSORIASIFORM DERMATOSES 155 

areas, and the addition of a little water enhances its value. Salicylic 
acid may be added to sulphur and resorcin salves up to five percent. 

Mercury. The ammoniated salt up to ten percent, is indicated 
in treating the scalp; the yellow oxide in treating lesions near the 
eyes. In the treatment of individual patches it is often useful to 
remove the scales, paint the affected area with a one percent, alco- 
holic solution of sublimate, and cover the lesion, after it is dry, with 
collodion. Salicylic acid when combined with ammoniated mercury 
enhances the latter' s value. All of these substances are to be used 
once a day. 

Tars. These may be used in simple ointments applied daily, or 
in combination with other medicaments, and in fluids. The first 
have already been described. They are most efficacious when applied 
after bathing. Wilkinson's ointment is an example of the combined 
variety, as is also Dreuw's. 

IJ Acid salicyli 

Chrysarobin , aa 10. 

01. Rusci 20. 

Sapon. virid. 

Petrol, flav, aa 24. 

Sig. 

This is used precisely as is Wilkinson's ointment. Tar in fluid 
form is employed pure or diluted. An example of the latter is 

^ 01. Rusci 25. 

Alcohol 95% ad 100. 

Sig. 

After a bath the patient is painted with the lotion whereupon he 
bathes again for from one-half to two hours. The tar is finally 
washed off and the skin anointed with a bland zinc salve. This is 
very efficacious treatment, does not stain the skin, and the patient 
does not go about smelling of tar. Pure tar often inflames the skin, 
and I prefer to use it diluted in alcohol because it does not irritate 
and dries more quickly. In scalp treatment, too, simple tar salves 
are useful. 

Light Therapy. Fractional doses of Roentgen rays, one HoLz- 
knecht unit a week, are of great service. Care must be exerted when 
they are used in treating the scalp because of the danger of alopecia. 
The Uviol lamp, giving an ultra-violet ray, is of limited value, and 
the Kromayer lamp, which irradiates only small surfaces, may be 
employed in treating inveterate patches. 



156 DERMATOLOGY 

It may be of service to recapitulate the above from the standpoint 
of regional therapy. Psoriasis of the scalp may be treated with am- 
moniated mercury salve, or this combined with a little salicylic acid. 
Tar salves and lotions are also useful. On the eyelids or brows two 
percent, ammoniated mercury, or one percent, yellow mercuric oxide 
are useful. On the face, these and tar salves are indicated, and on 
all of the areas just mentioned chrysarobin is to be avoided. All 
other forms of local treatment outlined are indicated on the rest of 
the body, but on the delicate covering of the scrotum, penis and 
vulva, chrysarobin, pyrogallol and salicylic acid must be employed 
with the utmost caution. 



PAEAPSOEIASIS 

Synonyms. Resistant maculo-papular Scaling Erythroderma. 

Definition. Parapsoriasis is a designation applied to a loosely united 
group of cutaneous diseases characterized clinically by an eruption of 
faintly yellow to buff, or pinkish-buff macules, papules, nodules or plaques, 
which have fine scales and which usually do not itch. According to 
Darier there are three main classes of this disease, and this point of view 
is generally accepted. These subdivisions are: (1) Parapsoriasis en 
gouttes; (2) Parapsoriasis lichenoi'de; (3) Parapsoriasis en plaques. 

Symptoms. (1) (Eig. 22) Parapsoriasis en gouttes, Brocq. (Guttate va- 
riety; Dermatitis psoriasiformis nodularis, Jadassohn; Pityriasis lichenoides 
chronica, Juliusberg.) On the trunk, arms and thighs pin-point to lentil 
sized papules develop, usually at adolescence. They are buff or red and re- 
semble syphilitic papules, but scale rather more than the latter, practically 
never involve the neck and face, are not accompanied by adenopathies and 
mucous patches, and the Wassermann reaction is absent. They do not itch, 
never involute, and from time to time new lesions develop. 

(2) Parapsoriasis lichenoi'de (Fig. 22) ; (Lichen variegatus, Crocker ; 
Parakeratosis variegata, Unna, Pollitzer and Santi; and perhaps Jadassohn's 
and Juliusberg's diseases as above). This variety is seen in the third and 
fourth generations and the dermatosis involves all parts of the body below 
the clavicles, usually not extending far beyond the knees and elbows. 
The eruption consists of yellowish scaling papules of a lichenoid character 
which coalesce and form a generalized lace-work. Amidst these small, 
glistening lesions, resembling those of lichen planus, are seen. There is 
no itching or involution. 

(3) Parapsoriasis en plaques (Fig. 23) ; (Xantho-erythroderma perstans. 
Crocker; Erythrodermie pityriasique en plaques disseminees, Brocq). The 
body becomes covered with scaling, moderately infiltrated plaques, varying 
in shade from fawn color to reddish brown or yellow. The patches are ir- 
regular in outline, sharply circumscribed, vary in number, persist, and do 
not itch. The skin does not feel infiltrated and the lesions never involute. 

Course. The disease begins insidiously in adult life or adolescence, in- 
creases slowly, and never disappears. The general health is not impaired. 



PSOEIASIS AND THE PSOEIASIFOKM DEEMATOSES 157 

Varieties. These have already been mentioned. 

Differential Diagnosis. Psoriasis, lichen planus, scaling seborrhoea, 
syphilis, and mycosis fungoides are simulated by parapsoriasis. In psoria- 
sis, the typical localization, involvement of the face and scalp, periods of 
remission, and the silvery scales are distinctive. Lichen planus (Chapter 
XIII) itches intensely, the lesions are umbilicated, violet or yellow, and 
glistening, and the buccal mucosa is frequently involved. Seborrhoea is 
seen on the scalp, in the folds of the body and flexor surfaces, possesses 
dense greasy scales, usually itches, causes loss of hair, and is prone to 
give rise to vesicular dermatitis. Syphilis may be ruled out along the 
lines mentioned in describing guttate parapsoriasis. Mycosis fungoides in 
the so-called premycotic stage simulates the plaque formed variety. My- 
cosis itches, and has a significant if not constant microscopic picture. 
Usually, only time will serve to make the diagnosis, and the likelihood of 
mycosis must always be seriously considered in cases of parapsoriasis en 
plaques. 

Etiology and Pathogenesis. The cause of the disease is unknown. 

Treatment. No treatment influences the disease. 

Prognosis. This is good as to life, but the malady cannot be cured. 



PITYRIASIS BOSEA (FIG. 24) 

Synonyms. Herpes Tonsurans Maculosus, Pityriasis Circinata; 
French, Pityriasis Posee (Gibert). 

Definition. Pityriasis rosea is a common macular, and at times 
maculo-vesicular, scaling cutaneous disease, which, but for lack of 
evidence of infection would be classed among the acute exanthemata, 
but which, because of its clinical features, must still be grouped in 
with the psoriasiform dermatoses. 

Symptoms. Although seen at all ages, the disease usually at- 
tacks young adults. It is rarely preceded by chills, chilliness and low 
fever, with, slight glandular enlargements. At first a single lesion 
appears on the body which grows larger, and after from a few days 
to several weeks, other spots appear on the trunk (Fig. 24), arms, 
thighs, and rarely on the legs, forearms and neck. Facial involve- 
ment is exceptional. The first lesion, known as the primitive patch, 
is pink, and spreads peripherally with a pink advancing margin upon 
which are situated fine scales. Central healing takes place leaving 
a fawn colored puckered area which gradually becomes normal. 
The other patches vary in size up to that of a dime or a quarter, are 
circular or oval, and tend to arrange themselves, particularly on the 
back, in sloping lines parallel with the ribs. Elsewhere they also 
follow the lines of cleavage. They, too, heal centrally and spread 



158 DERMATOLOGY 

peripherally as does the main lesion which they resemble in all re- 
spects but size. Itching is usually present and often intense. In 
from three to ten weeks involution is complete. Udo Wile has de- 
scribed vesicles in the centre of some lesions. 

Course. The disease is self limited. It usually is over in six 
weeks, but may last longer if not properly treated. It begins with 
a single patch and more lesions appear after a few days, or a fort- 
night. These increase in number during a second fortnight and 
then involution gradually takes place. 

Varieties. Save the vesicular form, no other varieties are 
known. 

Differential Diagnosis. Seborrhoea is the one disease closely 
simulated. At times, the most expert fail to make the diagnosis. 
Seborrhoea tends to be localized to the scalp, face, sternum, inter- 
scapular regions and body folds, but may be elsewhere. The scalp 
and face are practically always free in pityriasis rosea. Seborrhoea 
is more infiltrated and usually lacks the fawn colored centre, the 
entire patch being yellowish or brown, and the scales coarse, dense 
and greasy rather than fine. Ringworm and epidermophytia in- 
guinale (Chapter XXII) may somewhat resemble pityriasis rosea, 
but a demonstration of the pathogenic organisms of these maladies 
clears up the diagnosis. 

Etiology and Pathogenesis. A few facts concerning the disease 
are clear. It occurs prevailingly in spring and fall in an epidemic 
manner. Thus, it is clearly infectious. The fact that in a few 
instances fever and constitutional symptoms are present indicates 
the possibility of internal infection. On the other hand, the prim- 
itive patch preceding the generalized eruption points to the prob- 
ability of an external agent. This patch might possibly be the 
source of a toxaemia, accounting for the early systemic symptoms, 
but such a view is unlikely as the disease is too mild. Micro-organ- 
isms of one kind or another have been described, but the work is 
unconvincing. Some authors regard it as a skin reaction to a gen- 
eral metabolic disturbance, and ally the condition with erythema mul- 
tiforme. This is probably wrong because it looks different, acts 
differently and is localized differently from the latter. There are 
also those who consider the disease as evidence of a dyscrasia or of 
scrofula. These facts are mentioned only to be dismissed. 

Treatment. Purely external therapy suffices. I have yet to 
see a case which failed to disappear within three weeks when the 
following lotion was used : 



PSORIASIS AND THE PSORIASIFORM DERMATOSES 159 

Resorcini ., 6.0 

Zinc oxid 20.0 

Liquor calcis 50.0 

Alcohol 95% qs ad 200.0 

Sig. Shake well and apply twice daily. 

After about a week the skin may become dry and brittle. Then, an 
emolient salve (U.S.P. zinc ointment) should be employed, and after 
the dryness of the skin is better, the lotion is to be resumed. Irri- 
tating salves, such as the tars, salicylic acid, resorcin ointments, et 
cetera, are contra-indicated. They usually intensify the pruritus 
and protract the disease. Should the itching be severe, bromides 
are to be used, and locally, mentholated (two percent.) zinc stearate 
powder. 

Prognosis. This is always good. 

SEBOB-RJEOEA 

Definition. To define seborrhoea taxes ingenuity to its utmost. 
Opinions still vary greatly as to its nature and place among dermato- 
ses. It is considered by some primarily an affection of the seba- 
ceous glands, by others a dermatitis, by others non-inflammatory. 
There is no doubt that it favors sites at which the pilosebaceous or- 
gans are most numerous or most active, and it would be idle to deny 
the etiological significance of this circumstance. The question is 
further complicated by the fact that seborrhoeal soil readily gives 
rise to a dermatitis which was named seborrhoeal eczema by Unna, 
a term whose application has grown loose with time and which has 
been made to include all stages of the disease. Nor have those who, 
endeavoring to simplify the tangle by coining the expression 
seborrhoeal dermatitis, accomplished aught but confusion. Sabour- 
aud takes the stand that seborrhoea, pure and simple, is non-in- 
flammatory. This is wrong, as a most cursory inspection of the 
tissue shows. 

Seborrhoea is a mild, superficial inflammation at any time capable 
of becoming severer and developing into one form of dermatitis 
(eczema). In its quiescent phase it may exhibit the inflammatory 
signs of scaling, the functionally overactive signs of steatorrhoea, or 
both. In its more active phase, all of the signs of skin catarrh, but 
chiefly weeping and crusting, may be added to the above, even to 
the extent of so completely masking the latter as to preclude a correct 
diagnosis until the secondary signs have vanished. It is probable, 
too, that the disease may be, at least in part, parasitic. 



160 DERMATOLOGY 

By piecing all of these facts together into a tentative patch work 
a crude conception of the process may be reached. Seborrhoea is a 
disease whose starting place at least is in areas rich in pilosebaceons 
organs. It is possible that parasites participate in its causation, and 
it is characterized by scaling, or over-activity of the skin glands, or 
both, and is prone to be the starting point of an exudative inflamma- 
tion by no means limited to the sites originally affected. 

Symptoms. Seborrhoea usually begins on the scalp (Fig. 25) 
with scaling and itching. The scales are white or gray, fine or coarse, 
and often greasy and adherent if there is marked over-activity of the 
sebaceous glands. The drier form, also known as seborrhoea fur- 
furacea, pityriasis simplex, or eczema seborroeicum, is the common 
dandruff, the symptoms of which are known to everyone. At times 
the disease spreads to the neighboring skin over the forehead (Fig. 
25), neck, behind the ears, et cetera,, as a yellow to red, scaling in- 
flammation which when irritated becomes vesiculo-papular and pustu- 
lar, and weeps. This is the form which may truly be called sebor- 
rhoeic dermatitis, and which clinically and anatomically resembles 
any other dermatitis, the seborrhoeal soil forming the precipitating 
cause. (See Dermatitis, Chapter IX.) 

Other areas of the body subject to the malady are the front of the 
chest, the interscapular (Fig. 26) region, body folds, eyelids (Fig. 
25), eyebrows, umbilicus and genitalia. Scaling and itching are 
common to all, and the involved skin is often only slightly reddened, 
but not rarely deeply inflamed. Underneath the scales there are 
sometimes plugs which are hyperkeratotic casts of the patulous fol- 
licles below, and at times there are crusts of pure, dried grease when 
the flow of sebum is excessive. Such crusts are waxy and yellowish. 
When true dermatitis supervenes the crusts and scales assume the 
aspect of those which characterize the latter disease. Often in long- 
standing processes lichenification occurs. 

Course. The malady usually begins at adolescence, often in 
childhood, and not rarely in infancy. One form, milk crusts, char- 
acteristic of babyhood, starts shortly after birth with a yellowish 
crusting of the scalp probably representing a continuation of the 
vernix forming propensity, and it usually vanishes within three or 
four months. The other forms, if not properly treated, persist for 
life. Seborrhoea of the scalp often causes baldness. If allowed to 
progress unchecked, seborrhoea of the face leads to slight thickening 
of the skin, and the pilosebaceons follicles become permanently 



PSOEIASIS AND THE PSORIASIFORM DERMATOSES 161 

widened so that the integument looks coarse grained. These en- 
larged glands are constantly filled with exfoliated cuticle, sebum and 
dust, the entire mass forming comedones which will be further de- 
scribed in connection with acne. In addition to these the skin is 
often greasy. Acne vulgaris is frequently associated with sebor- 
rhoea, and the latter is always found with the former. Kosacea and 
some forms of simple dermatitis find their origin in seborrhoea. 

Varieties. Without too great elaboration of this phase of the 
disease certain varieties must be mentioned. 

Seborrhoea sicca is the commonest variety. The best example of 
this is dandruff. 

Seborrhoea oleosa is an oiliness of the skin, usually of the scalp 
and face, often over the sternum and between the shoulder blades. 
The dry and oily form may be associated, whereupon the scales be- 
come greasy. On the face, under the scales and crusts, are found 
inflamed patches, A similar process, not unlike psoriasis, is seen 
about the navel and on the rest of the body. 

Seborrhoeal dermatitis occurs at the sites already described in 
which ordinary seborrhoea is found. It may also remain restricted 
to the scalp, or spread to any of the areas mentioned. It is charac- 
terized by scaly macules, circular, oval or festooned in outline, or 
papules covered by a scale, or plaques, or a combination of the three, 
or it may be perifollicular, and it may weep, as ordinary dermatitis 
does, or there may be a free flow of oil so that the scales and crusts 
which are formed may either be greasy, or of the usual type seen in 
catarrh of the skin. Needless to say all of these forms have their 
special fanciful designations which it is useless for the practical stu- 
dent of dermatology to know. The scales near the skin are adherent, 
the upper layers being less so. All hairy portions of the body seem 
peculiarly vulnerable, but alopecia rarely occurs excepting on the 
eyebrows or scalp. When the body is involved, all sorts of diseases 
may be simulated, especially, however, psoriasis, pityriasis rosea, and 
ringworm. When the disease becomes universal it mimics the er- 
ythrodermas. 

Seborrhoeal baldness or alopecia has been alluded to. It may be 
partial or complete. The hair first falls out about the fronto- 
parietal regions and vertex, growing thinner and thinner. When the 
scalp is entirely bare it becomes glossy, pink and tense and the 
follicles are widened, but because they are made shallow by the trac- 
tion on the scalp, comedones usually do not form. Lanugo hair 



162 DERMATOLOGY 

usually remains. As a rule a band of true hair survives reaching 
from temple to temple and from the nape of the neck to the occipito- 
parietal junction. 

Diagnosis. Simple dandruff is easy to recognize. In children, 
seborrhoea must be differentiated from ringworm. This is usually 
easy since ringworm produces baldness either in large or small 
patches, and the areas involved are covered with gray, dry scales, or 
vesicles, or broken hair, are bald and finally are caused by fungi 
which may be demonstrated microscopically. There is also a diffuse 
form of tinea which closely simulates seborrhoea, and which can 
only be diagnosed by finding the fungi. Finally, the two diseases 
may co-exist. In adults, the diagnosis rests upon the presence of 
other symptoms of the disease, notably itching which is relieved by 
shampooing. It must be remembered that the normal skin desqua- 
mates ; we wash or rub off the scales constantly so that we do do not 
know we are scaling- On hairy parts of the body the scales cannot 
fall off so readily. Thus, we must rule out physiologic before we 
venture the diagnosis of pathologic scaling. 

Psoriasis favors the extensor surfaces, the scalp, and finally the 
rest of the body. It is a drier process, the scales are characteristic, 
and there are punctate hemorrhages on removing the scales, et cetera. 
(See this chapter above.) Only psoriasis of the scalp causes serious 
difficulty in differentiation, which is impossible without other evi- 
dences of either disease. Psoriasis, however, does not cause alopecia, 
and on the whole itches less than seborrhoea. Pityriasis rosea is 
characterized by an advancing, pink, scaling margin and a buff 
centre. There is a primitive patch larger than the rest, and the 
process rarely occurs above the clavicles. Ringworm is sparser and 
a demonstration of the fungi clears up the diagnosis. The diffuse 
erythrodermas may start as an apparent seborrhoea. The differ- 
ential points will be taken up in considering these diseases (Chap- 
ter XXII). 

Etiology and Pathogenesis. Simple seborrhoea is found in 
nearly all whites of both sexes from puberty up. Ethiopians have 
normally an oilier skin than whites, and among the Malay races the 
disease seems to be somewhat less common than among Caucasians. 
The c omm onness of the disease argues that it is either infectious, 
or inherently characteristic in the human race. Sab our and, Unna 
and Melassez have described bacteria which they consider pathogenic. 
These are the famous morococcus, bottle and acne bacillus. Without 
entering too greatly into the details of the question it may be stated 



PSOEIASIS AND THE PSORIASIFORM DERMATOSES 163 

that their evidence is largely circumstantial, but it is difficult to 
prove the pathogenicity of any cutaneous bacteria, and there is little 
to distinguish Unna's morococcus from Welsh's white staphylococcus 
which is always found all over the skin. The acne and the bottle 
bacilli present in seborrhoeal lesions are indistinguishable from sim- 
ilar organisms found elsewhere. Nor is there the remotest evidence 
that any of the alleged organisms is specific. All that can be said 
is that they are found in seborrhoea, and it may be stated with equal 
force that they are also found where seborrhoea is not. 

Certain other factors are important. Seborrhoea begins or gets 
worse at or about puberty. It favors areas where the sebaceous 
glands are largest, most numerous and active. It is at puberty, too, 
that these glands increase in size and activity. Whether this is due 
to endocrinous changes peculiar to the period in question or not, it 
is at present impossible to state. If so, the disease is primarily 
due to internal secretory changes. Should a specific organism ever 
be proved to be the causative agent, it would be so only in a 
secondary sense, a precipitating cause, the changes of puberty in 
the broadest meaning, being the predisposing one. The possible 
connection of disturbed sugar metabolism, which is after all prob- 
ably due to an endocrinous disturbance, has been indicated in the 
work by Schwartz and myself ; we found a large number of instances 
of hyperglycemia in seborrhoeic people. In close relation with this 
problem lies that of alimentary hyperglycemia, excessive ingestion 
of carbohydrates, and perhaps carbohydrate fermentation and in 
digestion. These matters are all relatively vague, and only the 
crudest clinical corroboration of their possible etiological bearing 
exists; but there is no doubt that in many cases the proper regula- 
tion of diet, restriction of carbohydrates, and curing of gastrointes- 
tinal disturbances improves and often actually cures seborrhoea. 

General causes of the usual variety, sedentary habits, constipation 
and the like have been mentioned, as they always are where opinions 
on etiology have no sounder foundation. Probably, in given in- 
stances these may aggravate or predispose to the malady, but definite 
proof is lacking. The most striking fact after all is the relation of 
the process to puberty. 

Treatment. Internal treatment consists in the main in an at- 
tempt to regulate the disturbed functions enumerated above. Of 
these, only the digestive group is amenable to therapy and here the 
matter resolves itself into the proper handling of hyperacidity, 
achylia and carbohydrate indigestion by diet and the use of a diastase, 



164 DERMATOLOGY 

or pancreatic extract and mild alkalies. Constipation must be cured 
by diet, and often mineral oil is of great value. In more complex 
digestive disturbances, the co-operation of a skilled internist or 
gastro-enterologist should be sought. 

Local Treatment. The seborrhoeal scalp is differently treated 
in its varying aspects. Itching, scaling, evidences of acute inflam- 
mation and falling of the hair constitute the clinical indications. At 
times there is a marked loss of hair without much scaling and itch- 
ing, or a great deal of scaling without much loss of hair. In general, 
the patient should be directed to shampoo once a week with some 
simple soap, but never green soap. Twenty-four hours before sham- 
pooing one of the following salves is to be applied sparingly to the 
scalp; either a five to ten percent, sulphur, a two to five percent, 
resorcin, a two percent, salicylic acid, or a five to ten percent, am- 
moniated mercury, in a base of cold cream, or equal parts of cold 
cream and lanolin. Vaselin is contra-indicated because it is hard to 
wash it out. Salicylic acid and ammoniated mercury together are 
very good. The salve loosens the scales and the shampoo removes 
them. Fine combing is bad. Every day, save the one on which 
the ointment is employed, a scalp lotion may be used. Beta naph- 
thol, salicylic acid, euresol, resorcin, and spirits of formic acid com- 
bined with one of these, represent those usually employed. A little 
bichloride of mercury in a strength of one to live thousand may be 
included. It has seemed to me advisable to eliminate cantharides 
and quinine, for in my experience I have found that the former some- 
times provokes dermatitis, and the latter, urticaria in the susceptible. 
Their value does not compensate for these unpleasant possibilities. 
A very excellent lotion which may be regarded as a type upon which 
to model others is 

I£ Euresol 

Spirit, acid, formicarum aa 10.0 

Glycerin 15.0 

Alcohol 95% qs ad 200.0 

Sig. Apply to scalp once a day. 

Salicylic acid 4.0 (two percent.) may be added to this, and if the 
patient desires the fluid to be perfumed, fluid extract of violets (0.6) 
or spirits of cologne (15.0) may be incorporated. The best method 
of applying a fluid of this sort is with a medicine dropper, the 
patient having been instructed to part the hair in parallel furrows 
separated by an inch, and to drop the fluid in the part. Thus the 



PSOEIASIS AND THE PSORIASIFORM DERMATOSES 165 

liquid will spread evenly over the entire scalp. The procedure re- 
quires only about ten minutes, and after the scalp is entirely covered, 
it should he rubbed lightly for a moment or so, but not massaged. 

Such treatment stops the itching and scaling, and usually the hair 
ceases to fall out within a month. New hair, however, does not 
grow readily after thirty. To promote the growth of hair many 
spurious methods of treatment have been devised, but the ranks of 
the bald-headed still remain unthinned. Massage, vibration with 
electric apparatus, and the like, all benefiting the treasury of the 
" hair specialist " more than the scalp of the patient, have been urged 
upon an eager public, and wave succeeds wave of credulous victims 
who despondently return to legitimate physicians after having been 
exploited by those who, without knowing medicine, make promises 
which it is not within the power of man to redeem. Recently the 
Kromayer and Alpine lamps have been widely employed in treating 
baldness, and although I can attest to their frequent value, 
I approach with utmost skepticism the claim that they can clothe 
the desert with verdure, or make the atrophied hair follicle give forth 
hair. Perhaps no better proof of the limitations of treatment is 
necessary than an inventory of the bald-headed dermatologists in 
existence. 

Upon the non-hairy parts of the body sulphur, resorcin, 1 ammo- 
niated mercury salves, and resorcin, euresol and sulphur lotions are 
of use in live to ten percent, strengths. Deeply scaling lesions 
should be treated precisely as psoriasis. X-Ray therapy is excellent, 
and in infiltrated patches the Kromayer lamp is useful also. The 
Roentgen rays are particularly valuable in oily seborrhoea. They 
atrophy the glands and thus lessen their over-activity and diminish 
the hyperkeratosis. This tends to overcome desquamation. 

When vesicular dermatitis is grafted upon seborrhoea, the treat- 
ment must be first directed to the secondary process. It is conducted 
along the lines indicated in the chapter on simple dermatitis. When 
the superimposed condition is well, the seborrhoea should be treated 
as outlined above. 

Prognosis. The individual attacks and the lesions of seborrhoea 
are easily cured, but recurrences are likely and numerous. In men, 
particularly, loss of hair is difficult to stop. At this point I should 
like to mention a view which I have held for years and which 
Pollitzer once expressed at a meeting of the American Dermatolog- 

1 In red-headed and blonde people resorcin should be used circumspectly since 
it sometimes turns the hair green. In white-haired people this usually happens. 



166 DEKMATOLOGY 

ical Association, namely, that not all baldness is pathological, bnt 
that it is normal in a large percentage of men, at least. It is bio- 
logical in that the hair is a secondary sexnal characteristic, useless 
after a certain age. To the student of Darwin this point will be 
clear ; to one versed in modern medicine it will be apparent that this 
is equivalent to asserting in another form that the disease is due to 
a change in the internal secretions. 




PSORIASIS 



Scalp involvement and the small, or guttate type of lesion are illustrated. 
The white, delicate mica-like character of the scales is shown. Near the left 
scapula, a patch is forming through coalescence. The scalp involvement alone 
excludes pityriasis rosea and parapsoriasis; the nature of the scales, seborrhoea. 




Fig. 21. PSORIASIS IN PATCHES 

In this form, as here shown, large, thickened, red plaques form. White scales 
develop. The margins are festooned by coalescence with smaller outlying patches. 
Here and there, small isolated papules are seen. 




Fig 



PARAPSORIASIS 



This variety of parapsoriasis is characterized by small buff papules some of which 
suggest lichen, others psoriasis. Both have small fine scales. The lesions rarely 
appear far above the clavicles or much below the lower third of the thigh. There 
are no subjective symptoms, and great chronicity distinguishes the affliction. 




Fig. 23. PARAPSORIASIS 

This is the plaque form of parapsoriasis, or erythroderma pityriasique en plaques 
disseminees. The lesion is extensive, yellowish, slightly infiltrated and scaling. 
There is no itching. This condition at times precedes mycosis. The face is usually 
free in parapsoriasis. The black spot on the left thigh is the result of a biopsy and 
has nothing to do with the disease. 







PITYRIASIS ROSEA 



This condition is characterized by oval or rounded flat papules interpersed among 
which are minute lesions. The long axis of the oval lesions parallels the skin's 
cleavage lines. A red, swollen margin encloses the yellow, or buff, slightly puckered, 
scaling centre. Usually the general outbreak is preceded by one large patch. The 
face, legs and forearms are rarely involved. Thus seborrhoea is ruled out. The 
scales are finer and not so white as in psoriasis, or so greasy and yellow as in 
seborrhoea. 




Fig. 25. SEBORRHOEA, SCALP 

Seborrhoea includes a group of conditions (Fig. 27) featured by in- 
flammatory lesions. These are small or large, flat papules or patches 
which are yellow or brownish, and covered by greasy white, yellow, 
or grey scales. They favor the flexor surfaces, chest interscapular 
regions, back, face and scalp. This picture represents the last form. 
The lesions individually resemble psoriasis, save for the greasiness of 
the scales, but the disease differs from psoriasis as to location, the 
ease with which it leads to vesicular dermatitis, and the frequency 
with which it leads to baldness. 




Fig. 20. SEBORRHOEA, BODY 

This picture is typical. The patches are small or large, and vary 
greatly in outline. The scales are not conspicuous in this patient, 
but the localization is typical. (See note, Fig. 25.) 



CHAPTEK XII 

THE ERYTHRODERMAS OR EXFOLIATIVE DERMATITIS 

Here again, as in all instances in which it is endeavored to group 
dermatoses, many factors enter into conflict. Regarded from one 
standpoint, the erythrodermas, which are nothing but diffuse, in- 
flammatory, red, desquamating diseases of the skin, may be divided 
into two groups, primary and secondary. The primary, which be- 
long together only because of the circumstance that they arise from 
no forerunning cutaneous condition, are dermatitis exfoliativa of 
Wilson-Brocq, pityriasis rubra of Hebra, dermatitis exfoliativa neo- 
natorum of Ritter, erythroderma desquamativa neonatorum of Lei- 
ner, erythroderma ichthyosiforme congenita of Brocq, and dermatitis 
exfoliativa epidemica of Savill. The secondary varieties are those 
which arise from any disseminated maculopapular disease which 
under certain conditions becomes universal, and which when universal 
loses its identity so that its true nature cannot be recognized. It 
remains unrecognizable until the process reassumes its original form. 
Psoriasis, scaling dermatitis, lichen planus and lichen acuminatus are 
capable of this. 

Regarded from another viewpoint, the conditions may be classified 
as characteristic of the newborn and of the adult. The former 
comprise Ritter's and Leiner's diseases and Brocq's congenital 
ichthyosiform erythroderma. All the others belong to the adult 
group. 

Etiologically, so far as anything is known at all, all of the condi- 
tions are individual, and only the infantile forms have a common 
bond. This tie is a loose one and consists simply of the fact that 
the infant human being is attacked. There is no doubt whatever 
that these conditions again are examples of cutaneous reactions, for 
widely varied causes may excite similar scaling processes, and it is 
equally likely that the same cause may provoke desquamative pro- 
cesses differing in appearance. With these facts clearly in mind 
and fully appreciating that the essentially unrelated entities are 
assembled in one chapter because of accidents of objective similarity 
and ignorance of their ultimate causation, we may proceed to a 
study of their clinical features. 

167 



168 DERMATOLOGY 



DERMATITIS EXFOLIATIVA 

(Wilson-Brocq) 
This is a very rare condition. It starts as bright red erythematous 
patches covered with coarse scales resembling pie crust. Rapidly the entire 
body is involved, no area being spared. The hair grows brittle and lustre- 
less and may fall. The nails become thick and dull and may also fall 
out. Usually the process is dry, but it may weep. Occasionally mild 
systemic symptoms inaugurate the disease. When in full bloom the 
malady has a distinctive appearance. The entire body is bright red and 
covered with coarse, large scales which peel back at their edges. There are 
often slightly enlarged glands, but the general health suffers only slightly. 
Periods of remission, alternating with recrudescences characterize the pro- 
cess and usually, even after lasting for many decades, the patient recovers, 
although a few deaths have occurred. Quinine, by mouth or even intra- 
venously administered is of great value, and such drugs as pilocarpine, 
aspirin and the like have been used with success. Locally, simply salves 
and oils are to be employed. The etiology of the disease is totally unknown. 

PITYRIASIS RUBRA OF HEBRA 

Synonyms. Dermatitis Exfoliativa; Lymphadenitic Erythro- 
derma. 

Definition. Pityriasis rubra 1 is a rare, chronic, diffuse disease 
leading to atrophy of the skin after months or years of illness. It 
ends in death. 

Symptoms. Usually the onset is gradual and takes place as 
desquamating erythema in the knee and elbow flexures. From these 
sites it extends until the entire body is covered by red, uninfiltrated, 
thin integument from which fall an abundance of scales, usually 
fine, but sometimes coarse. Atrophy occurs and the skin stretches, 
becoming tense and thin so that over bony prominences and in body 
folds, it cracks or ulcerates. The lymphatic glands become huge; 
the hair and nails after growing dry and dull fall out, the patient 
emaciates, weakens, and atrophy of the facial skin causes ectropion 
of the eyelids. Thus, conjunctivitis develops. Moderate or severe 
pruritus is present, and there is regular fever, usually highest at 
night, with a rapid pulse, sweats, diarrhoea, and often chills, stupor 
and rigors. Albuminuria and icterus are also frequently encoun- 
tered. 

Course. The illness starts as described, involves the entire body 
in from a few weeks to two years, runs a chronic, progressive course 
with the complications enumerated above, and after a year or several 

i This must not be confused with Pityriasis rubra pilaris which is synonymous 
with lichen acuminatus (Chapter XIII). 



ERYTHRODERMAS OR EXFOLIATIVE DERMATITIS 169 

years ends fatally. Death is determined by one of the complica- 
tions mentioned, or asthenia, pneumonia, bronchitis, albuminuria, 
pulmonary edema, or some intercurrent infection. Pulmonary or 
generalized tuberculosis are usually discovered at autopsy. 

Differential Diagnosis. Dermatitis exfoliativa (Wilson- 
Brocq), premycotic erythroderma and the secondary erythrodermas 
must be differentiated from Hebra's pityriasis rubra. The great 
prostration in the last named disease, the glandular enlargements, 
fine scales, atrophic skin, progressive and unremitting course, and 
the consistent decline of the patient are characteristic. Wilson's 
form has periods of remission and usually ends in recovery; the 
scales are coarser, the patient is in better general health and the skin 
does not atrophy. In premycotic and preleucemic erythroderma, 
the diagnosis cannot usually be made, save in retrospect when the 
patient has mycosis or leucemia. This subject will be discussed in 
detail later on (Chapter XXVI). The secondary forms may be 
recognized by their milder course, remissions during which lesions 
typical of the primary disease appear somewhere on the body, and a 
greater degree of infiltration. Lipmann-Wolf in a discussion of this 
subject at the Berlin Dermatological Society (May 14th, 1912) said 
that the diagnosis of pityriasis rubra of Hebra could not be made 
during life, that death was the pathognomonic feature of the condi- 
tion. 

Etiology and Pathogenesis. Very little is known of the cause 
of the malady. Lipmann-Wolf on the occasion mentioned above, 
quoted Saalf eld's view that it was not a disease sui generis, but a 
cutaneous reaction, an attitude in which Brocq concurs. Jadassohn 
pointed out its relation to tuberculosis. A great deal of evidence to 
this effect exists and undoubtedly, in at least one form of the disease, 
this factor is causative. Hence, pityriasis rubra may be included in 
the tuberculides (Chapter XXV). In a typical case I saw in con- 
sultation and had the opportunity to study, the patient had carious 
teeth, pyorrhoea and apical abscesses. The usual prognosis was 
made, but after his teeth had been extracted he recovered completely 
and, at the present writing, precisely seven years after the grave 
prognosis had been made, the patient is perfectly well and attending 
to his affairs, following an illness which had grown progressively 
worse for two years. 1 , 

Treatment. This is purely symptomatic and should be con- 

i In another instance the theory involved in the first case was applied without 
success. 



170 DEKMATOLOGY 

ducted along the lines indicated in discussing Wilson's disease. 
Tuberculosis should be considered and, if present, it naturally fur- 
nishes the general therapeutic indications. 
Prognosis. The prognosis is grave. 

SAVIXl/s DISEASE 

This disease is also known as dermatitis exfoliativa epidemica. An epi- 
demic skin disease occurred in London in 1891 where several hundred 
cases were reported. Two types were described; one corresponding to a 
universal, exfoliating and weeping dermatitis, the other to pityriasis rubra 
of Hebra. The onset was acute without prodromata, but accompanied by 
vomiting and diarrhoea, and in some instances by pharyngitis. The head 
and upper extremities were favored, although other sites were involved at 
the outset, and gradually the rest of the body became affected. In the 
young, the cervical glands were enlarged. Savill described a papulo-ery- 
thematous stage, lasting up to eight days. The papules were shotty, single 
or grouped in circles. Then an exudative stage appeared lasting up to 
eight weeks, in which there were scaling, vesiculation and diffuse erythema. 
Finally, a period of defervescence closely simulating pityriasis rubra of 
Hebra appeared. The cause has never been determined. The mortality 
reached as high as thirteen percent. 

DERMATITIS EXFOLIATIVA NEONATORUM 

(Eitter) 

This disease is also known as Dermatitis erysipelatosa. It was first 
described in 1878 by Bitter von Rittershain. It begins about the second 
week of infancy, starting as an erysipelatous rash about the mouth, whence 
it extends to the face, neck and entire body. Crusts, scales and scabs 
form, and the desquamating areas are uneven, red and greasy. The trunk 
is more involved than the extremities and the worst area is the scalp. 
The buccal mucosa is red and exfoliates. Fissures form about the lips 
and anus, and at first the infant gains, but in from ten days to several 
months about half of the patients die, the others recovering entirely. 
Death is caused by an intercurrent disease such as pneumonia, or chronic 
indigestion with marasmus. 

ERYTHRODERMA DESQUAMATIVUM NEONATORUM 

(Leiner) 

This disease was first described in Leiner in 1907. The ensuing is an 
abstract of the original description. At first the disease involves the 
scalp extending to the face and the rest of the body as an exfoliating, 
crusted, fatty group of lesions which are most characteristic on the fore- 
head, or as slightly scaling, circular lesions at the same site. The scales 
are thickest on the brows, thinnest on the cheeks; the eyelids are red, their 
margin thick, the lashes sparse, and excoriations appear on the involved 
integument. The body is red, scaling, and the skin is thickened, dry, 
shiny and even velvety. In places it atrophies or becomes ragged. Some- 



ERYTHRODERMAS OR EXFOLIATIVE DERMATITIS 171 

times the scales are imbricated. Desquamation appears on the hands and 
feet, the nails are disturbed in their growth and sometimes fall out, and a 
greasy exudation arises in the body folds. The mucosa remains normal. 
Leiner emphasizes the fact that dyspepsia accompanies the picture, and 
the disease occurs almost exclusively in breast fed babies. Its etiology 
is little known; some regard it as pemphigus; others as an infantile form 
of pityriasis rubra of Hebra; some think it due to breast milk, others to 
an infection. Brandweiner regards it as baby seborrhoea. Death is due to 
an intercurrent disease or marasmus, and most of those affected die. 

EBYTHEODEEMA ICHTHYOSIFOEME CONGENITUM 

(Brocq) 

This is a rare scaling erythematous disease presenting some features of 
exfoliative dermatitis and some of ichthyosis. It is not yet conceded to be 
a definite entity. 

Besides these conditions must be mentioned a disease vaguely re- 
lated to the dermatoses included in this chapter. It is a generalized 
foliaceous erythema known as erythema scarlatiniforme desquam- 
ativum recidevans of Fereol and Besnier. It is also called scarlat- 
inoid erythema, scarlatinoide, roseola scarlatiniforme, and dermatite 
exfoliante aigue benigne by Brocq. It begins as a generalized er- 
ythematous exfoliation. Its onset is sudden, accompanied by head- 
aches, chilliness, fever (100°-102°) and the rash involves the body 
folds, extremities, and gradually the whole body, sometimes including 
the head. It resembles scarlet, measles and German measles, and 
after the erythematous stage fine scaling sets in. There is slight 
or no sore throat, no Mindt's spots, no glandular enlargement, and 
recurrences are common. These facts connected with its uniform 
benignity differentiate it from the commoner acute exanthemata. 



CHAPTER XIII 

THE LICHENS AXD LICHENIFICATION 

This group of diseases is a comprehensive one, and includes many 
conditions the causal identity or even close relationship of which is 
not established. The confusion is historic and originally arose 
from a diffuse and unsound application of the purely figurative word 
lichen. Botanically. a lichen is a dry, mossy, scaling growth found 
on stones, stumps of wood and the like, and since many skin diseases 
roughly resemble this plant, the purely fanciful designation was 
adopted in medicine. Many diseases, not called lichen, show this 
resemblance much more than others to which the term is applied. 
Psoriasis, scaling dermatitis, pityriasis versicolor all do so infinitely 
more than lichen planus. In the technical manner of employing the 
term sanctioned to-day, a lichen has acquired the significance of a 
rather raised infiltration composed of single or coalesced papules 
which scale, and lichenification is the name of the pathological pro- 
cess by means of which lichens are produced. Lichenification also 
has become synonymous with the word thickening, and lichenified 
with thickened. 

It would be unprofitable, not to say confusing to those uninterested 
in dermatological dialectics to review the history of the name, and the 
literary and clinical evolution of the diseases in this group as we to- 
day conceive them. They all have common points of resemblance. 
They are thickened, impliable, scaling, more or less red, buff, or 
violaceous lesions which itch, and are composed of small papules 
single or grouped, follicular or non-follicular, which tend to coalesce 
into fairly circumscribed, scaling patches of rather distinct config- 
uration. These patches are called patches of lichen, lichenification, 
or lichenified plaques. In the various diseases to be described the 
primary papules, however, have distinctive features, and the differ- 
ent conditions have peculiarities of site, appearance and course. 
TThen the ensuing matter has been thoughtfully studied, it will be- 
come clear that the complexities of the question are neither so numer- 
ous nor insuperable as they appear at first. 

Older authors, as Willan, described five types of lichens: lichen 

172 



THE LICHENS AND LICHENIEICATION 173 

simplex, later called lichen simplex acutus, or prurigo mitis ; lichen 
pilaris, now known as perifollicular seborrhoea; lichen lividus, a 
purpura ; lichen tropicus, now called sudamina ; and lichen urticatus, 
now called prurigo mitis, or mild papular urticaria. Rayer included 
lichen agrius, known now as prurigo ferox. These names are re- 
corded because readers may encounter them elsewhere, and to em- 
phasize the fact that they are not lichens in the modern sense. 
To-day we might well divide the group as follows : 

I. True Lichen 

1. Lichen planus (Wilson). 

2. Lichen ruber acuminatus of Hebra, or pityriasis rubra 

pilaris of Deverige (included out of respect for tradition). 

II. False Lichens. 

1. Follicular 

a. Lichen, pilaris (Bazin), or keratosis pilaris simplex 

(Chapter XY). 

b. Folliculitis rubra (Wilson), probably TTnna's ulerythema 

ophryogenes (Chapter XY). 

c. Lichen tropicus (prickly heat). 

d. Lichen spinulosus 

2. Toxic lichens, lichen agrius or prurigo, lichen urticatus or 

infantile chronic urticaria. 

3. Specific lichen 

a. Lichen syphiliticus (see syphilis, Chapter XLII). 

b. Lichen scrofulosorum (see tuberculides, Chapter XXY). 

c. Lichen nitidus (probably tubercular). 
III. Lichenification. 

1. Primary-lichen simplex chronicus (Yidal) or neurodermite 

(Brocq). 

2. Secondary-lichenification (Brocq) lichenization (Besnier), 

found in itching dermatoses. 

Of these, lichen planus, lichen acuminatus, lichenification and 
lichen chronicus simplex will be studied in this chapter, for they are 
the sole surviving lichens in which the term is more or less justifiable. 
Lichen nitidus will be here mentioned because its true place is not 
yet definitely known. Lichen spinulosus somewhat suggests lichen 
acuminatus, but is actually more like keratosis pilaris (Chapter 
XY). In a restricted sense there is but one true lichen, lichen 
planus, but this point need not be too narrowly emphasized. Thus, 
for practical purposes the clinical student may regard the lichens as : 



174 DERMATOLOGY 

1. Lichen planus (one form of the so-called lichen ruber) 

2. Lichen acuminatus (another form of the so-called lichen ruber) 

3. Lichenification 

a. Primary 

b. Secondary 

4. Lichen nitidus 

But one further condition must be mentioned before we begin our 
clinical survey, and that is lichen ruber. A classical battle once 
was waged about the relation of lichen planus to lichen acuminatus. 
It had been thought that the two latter were different phases of a 
single process, and that lichen ruber included both. The only thing 
to be remembered is that the term lichen ruber is obsolete, although 
it was for a time retained in the designation lichen ruber planus. 

LICHEN PLANUS (FIG. 27) 

Synonyms. Lichen ruber planus (obsolete). 

Definition. Lichen planus is an infrequent, though not rare, 
itching papular eruption, involving the skin and buccal musoca, in- 
clined to be chronic, often acute, and capable of assuming many 
forms. Its elementary lesions tend to become confluent forming 
plaques, which scale, and its color varies from waxy buff to purple. 

Symptoms. As a rule the disease appears on the front of the 
wrists or above the ankles, as an eruption of pinpoint, waxy, flesh- 
colored or pink papules which itch. The papules are polygonal (Fig. 
27) or angular, have steep sides, show a central tiny depression or 
umbilication, and are covered by a firmly attached small, white scale. 
Although many papules remain discrete throughout, an equal number 
may become confluent forming groups of lesions three to five milli- 
meters broad which are elevated, red to violaceous or purple in color, 
and covered by thin, adherent, white scales. Larger patches or 
plaques are usually purple, this shade shining through a white or 
gray film partly produced by the desquamation. The sides of the 
plaques are steep, the surface is furrowed by minute intersecting 
lines, and the scales, as mentioned above, adhere firmly. The buccal 
mucosa (Fig. 28) is nearly always involved. On the sides of the 
mouth, tongue and lips are seen tiny snow-white papules correspond- 
ing to those on the skin, or leucoplakial sheets, corresponding to 
the cutaneous plaques like which they, too, are furrowed. Almost 
the entire body may be included in the process, but the neck, face and 
scalp rarely are, and the palms and soles never. The sites of election 



THE LICHENS AND LICHENIFICATION 175 

are the front of the wrists, legs above the ankles, buccal mucosa, glans 
penis and the greater labia. 

Itching is frequently intense. There is rarely vesicle formation 
except after the use of arsenic which is perhaps the cause of the so- 
called pemphigoid lichen. Lichen papules may arrange themselves 
in rings (Fig. 29), lines, plaques, or in some combination of these 
figures, and they may be large, small, or obtuse. As a rule, no gen- 
eral symptoms accompany the outbreak, but fever has at times been 
noted, and very rarely high fever and prostration. Ordinarily, but 
not always, the distribution is symmetrical; at times the lesions 
cover the entire trunk and extremeties, and not infrequently there 
appears an acute general outbreak of minute papules, which rapidly 
assume the appearance of those seen in the form that develops more 
slowly. It is essentially a disease of adult life, and most excep- 
tional in children. 

Involution takes place with hyperpigmentation, and sometimes de- 
pigmentation at the sites of the vanishing papules. The discolora- 
tion gradually fades, the normal hue of the skin finally returning. 

Course. The onset usually is gradual, but sometimes acute. 
Months or years may be consumed in its course, but nearly all of the 
cases end in recovery. Some are inveterate, however, and the buccal 
lesions are very refractory, although in a great many instances even 
these disappear. Recurrences are exceptional. 

Varieties. There are many varieties of lichen planus, but these 
are chiefly due to accidents of arrangement, distribution, and the like. 

I. Common lichen; Lichen planus (Wilson) (Fig. 27) 
II. Hypertrophic Forms 

1. Lichen planus hypertrophicus (Vidal and Leloir) (Fig. 

30) 

2. Lichen planus verrucosus 

3. Lichen planus obtusus 
III. Atrophic Forms 

1. Lichen planus sclerosus et atrophicus (Hallopeau) 

2. Lichen planus morphoeicus (Crocker) 

3. Lichen albus (von Zumbusch) 

These are identical. 
IV. Lichen Pemphigoides 
V. Forms varying as to distribution, arrangement, et cetera 

1. Lichen of the mucosa (Fig. 26) 

2. Lichen annularis 



176 DEEMATOLOGY 

3. Lichen moniliformis 

4. Lichen striatus or linearis 

5. Lichen planus erythematosus 

Lichen Planus Hypertrophicus (Fig. 30) usually occurs on the lower, 
sometimes the upper extremities, in irregular strips or oval patches, or irreg- 
ular reddish-brown or purple plaques. Horny excrescences and scales de- 
velop. The itching is severe. 

Lichen Planus Verrucosus is a further exaggeration of the preceding, 
in which the excrescences become warty. 

In Lichen Obtusus the papules are larger than in ordinary lichen, and 
flat or convex in outline. 

The three atrophic forms, Lichen Sclerosus, Morphoeicus and Albus, con- 
sist of white papules, or ordinary papules surrounding a clear white, 
atrophic center. The former are outlined by a violaceous or red areola. 
The white papules, even when coalescent, do not lose their individual shape 
entirely. Plugs arise from the depressions or umbilication3. They often 
spring from the sweat pores. Usually the trunk is affected. 

Lichen Pemphigoides is extremely rare. Bullae arise on the patches or 
plaques. 

Lichen Annularis (Fig. 29) is formed by the papules grouping themselves 
so as to form a ring, or more rarely by extending peripherally while they 
heal within. This form is commonest on the glans penis. 

Lichen Moniliformis is rare. It consists of papules arranged in the 
manner of beads in a necklace. 

Lichen Striatus or Linearis consists of a linear arrangement of the 
papules. 

Lichen Erythematosus simply indicates that the papules are extremely 
red. 

Differential Diagnosis. In all cases the diagnosis rests upon 
the appearance of the lesions and their distribution. The papules 
are polygonal, steep and umbilicated, covered by an adherent scale; 
they are waxy buff or pink, reddish or violaceous. They favor the 
front of the wrists, the legs above the shoetops, the buccal mucosa and 
the glans, and itch more or less. In the rarer varieties concomitant 
typical lesions may be found indicating the true diagnosis. The 
diseases to be differentiated are psoriasis, parapsoriasis, vesicular der- 
matitis, lichen syphiliticus, lichen scrofulosorum, lichen nitidus and 
lichen simplex. Lichen sclerosus must be distinguished from that 
variety of scleroderma or morphoea (Fig. 40) known as white spot 
disease, and idiopathic macular atrophy, while buccal lichen must 
be differentiated from simple and luetic leucoplakia (Fig. 74). 
Psoriasis favors the extensor surfaces and scalp, which is never the 
case in lichen, while the latter is often, if not always, in the mouth, 
and the former never. Removal of the scales in psoriasis causes 



THE LICHENS AND LICHENIFICATION 177 

punctate bleeding; the scales are silvery and imbricated. None of 
these features exist in lichen. Parapsoriasis does not itch, is not in- 
filtrated, and never involves the mouth. Indeed only one variety of 
this disease, namely, pityriasis lichenoides chronica, or guttate para- 
psoriasis might cause confusion. But the scales are less adherent 
than in lichen planus, the lesions are lenticular rather than polygonal, 
and never are waxy or violaceous. Vesicular dermatitis and su- 
damina from a distance resemble fresh disseminated lichen, because 
of the glistening yellowish to pink color. On close inspection the 
lesions are found to be vesicles and not papules. Lichen syphiliticus, 
or the small, lenticular papular syphiloderm, closely resembles lichen 
planus in all respects. Lichen syphiliticus is one of the few specific 
eruptions that may itch. This is more common, however, in negroes, 
and furnishes a further point of confusion with lichen planus. The 
syphilitic variety, however, is usually found to be follicular, which 
lichen is not, and other features of syphilis are present — enlarged 
glands, mucous patches, and the Wessermann reaction. Lichen 
scrofulosorum is a rare disease, most often seen in children at 
an age earlier than lichen planus is likely to occur. The lesions 
themselves are similar in the two conditions, but those of the 
scrofulous variety are grouped in circular patches and rarely 
coalesce. The sites involved are primarily the sides of the trunk, 
buttocks, and upper part of the thighs, and not seldom evidences of 
general tuberculosis are present. Lichen nitidus is extremely rare. 
The mere fact that among other sites it is found upon the palms dis- 
tinguishes it from lichen planus. Lichen simplex or neurodermatitis 
has favored sites over the vertebra prominens, in the elbow and knee 
flexures, and over the small of the back. It may also occur elsewhere 
and simulates only the plaques of lichen planus. The color of the 
two differs, that of lichen simplex being redder, and the scales in this 
disease larger; excoriations often are present, and the margins are 
not so sharp, often being studded with small papules at their 
periphery. Lichenification is differentiated from lichen planus by 
an appearance closely resembling that of lichen simplex, and by the 
further fact that it exists in combination with some other itching 
disease to which it is a sequel. Lichen planus must also be dis- 
tinguished from lichen acuminatus. This will be discussed below. 
Etiology and Pathogenesis. Although nothing is really known 
of the etiology of lichen planus inferential evidence exists that there 
are two groups of causative factors, — nervous and infectious. In ad- 
dition to this a plethoric literature, purporting to prove the toxemic, 



178 DERMATOLOGY 

reflex and local infectious nature of the malady, precisely as in all 
other illnesses of unknown origin, need be mentioned only to be dis- 
missed. The reasons for dwelling upon the possibility of its relation 
to the central nervous sytem are that it occurs prevailingly in the neu- 
rotic, or after mental, psychic or emotional shock. This is more 
than fanciful as significant instances occur in every dermatologist's 
experience. The reasons for seriously regarding infection as the pos- 
sible cause may be summed up in the fact that arsenic and mercury 
cure it, and the time has long since passed when the efficacy of 
these medicaments could be explained on the ground that they are 
alteratives. Whether the pathogenic agent is a bacterium or pro- 
tozoon no one knows. The response of the disease to the two metals 
mentioned speaks for the second assumption. Hazen, in discussing 
a paper by Lieberthal, announced that he had found a spirochaete, 
the pathogenic nature of which he hinted at. What reconciliation 
there may be between the nervous and infectious theories it is hard 
to understand, unless the former indicates that the physiology of the 
host is so altered as to make him susceptible to the specific undis- 
covered agent in question. 

Treatment. Of all internal medicaments employed the only two 
of any value are arsenic and mercury. Arsenic is given in increas- 
ing doses, whether Fowler's solution, arsenic trioxide, the cacody- 
lates, or Asiatic pills are preferred (Chapter XI. Treatment of 
psoriasis). Mercury may be administered by mouth or injection as 
in syphilis. In my experience mercury is the more efficacious drug, 
and the protiodide is its must useful salt. At first pills (Gr. % 
plus, t. i. d. p. c.) are given, and the dose is increased daily until 
the lesions begin to fade, whereupon internal treatment is no longer 
necessary. 

Two indications are to be met as to the local treatment, — the 
itching, and the need to cause involution of the lesions. Although 
tars, salicylic acid and resorcin have been employed, it has seemed to 
me that they do not hasten the disappearance of the papules in dis- 
seminated lichen, and furthermore, they often irritate the skin, pro- 
voking erythematous and vesicular dermatitis. Thus, I have learned 
that a mentholated powder (two percent, of menthol in zinc st ear ate), 
used two or three times a day, or mentholated calamine and zinc 
lotion similarly employed control the pruritus. In addition to this, 
divided doses of X-Rays limit both the pruritus and duration of 
the disease, reducing the course to a maximum of three, instead of 
from six to twelve, months. 






THE LICHENS AND LICHENIFICATION 179 

In hypertrophic and verrucous forms salicylic acid plaster (ten 
to twenty percent. ) , and two to four H doses of X-Rays, and the use of 
the Kromayer lamp work best, coupled with mercury internally. In 
atrophic lichen the process may be stopped with the internal medi- 
cation already mentioned and with X-Rays, but the atrophy is 
permanent. Buccal lichen, if not responsive to mercury and arsenic, 
is intractable. After the lichen papules are gone a hyperpigmenta- 
tion persists for months. Nothing hastens its disappearance and it 
is a characteristic feature of the disease. 

Prognosis. As regards life, the prognosis is nearly always good, 
although isolated instances of fatal termination are on record. 
Ordinary disseminated lichen may persist for a year or even more 
when neglected. Otherwise, its cure may be accomplished within a 
maximum of four months. The atrophic form may be limited by 
therapy but the atrophy persists. Buccal and hypertrophic forms 
are difficult to cure, but often this desirable result is attainable. 
The other forms being merely aberrances of the common variety, 
respond readily to the usual treatment. The disseminated variety 
rarely recurs ; the localized forms sometimes do. 

LICHEN ACUMINATUS (FIG. 31) 

Synonyms. Lichen ruber (Herba) ; 1 Lichen ruber acuminatus 
(Kaposi) ; x Pityriasis rubra pilaris (Devergie). 

Definition. Pityriasis rubra pilaris is a chronic folliculitis with 
hyperkeratosis, the clinical features of which are conical, red, scal- 
ing papules containing a horny plug. The lesions are situated about 
the hair and sweat follicles in a more or less definite distribution. 
At times the process becomes generalized and it often is preceded by 
scaling at the sites subsequently to exhibit the papules. 

Symptoms. At the start, gradual as a rule, though sometimes 
sudden, the patient shows moderate scaling on a slightly thickened, 
rough and somewhat erythematous base. Then pink, buff, red, violet 
or even purple papules arise, which are conical and in the centre of 
which there is a horny plug only slightly elevated above the volcano 
shaped papules. The lesions are from one to three millimeters broad 
and high. The hands, feet, face, scalp, eyebrows and body surface 
are affected, the order of frequency being indicated by the sequence 
just mentioned. Palmar (Fig. 31) and plantar hyperkeratosis de- 
velops, and the buccal mucosa is very rarely involved, the lesions 
here resembling those of lichen planus. By far the great majority 

i Obsolete. 



180 DEEMATOLOGY 

of cases are not extensive, the lesions remaining localized to certain 
places, the site of election being the back of the fingers. On the 
whole the extensor are rather more favored than the flexor aspects. 
The papules may remain discrete, but are often packed together. 
Plaques may form, or exfoliating patches, and later in the disease 
the lymph glands enlarge and marasmus supervenes. 

To the touch the skin feels rough. When the face is involved 
ectropion of the lower lids develops; the conjunctivae are inflamed, 
becoming red and everted. Thus lachrymation and crusting of the 
lids arise. The patient is sensitive to cold, and the moderate but 
constant itching and tension of the skin become cumulatively more 
annoying as the resistance and general health decrease, leading to 
wasting of the body. There is not, however, a progressive augmen- 
tation of the severity of the disease. Periods of complete remis- 
sion are usually encountered with ensuing relapses, each of which 
is more prolonged and severer than the preceding one. Often, 
however, permanent recovery from the attacks has been noted. In 
the severer forms the aspect of exfoliative dermatitis is assumed, 
and in many of the milder ones that of chronic dermatitis with 
weeping and crusting. The nails and hair grow dull and brittle 
and sometimes fall. 

Course. The disease starts suddenly or gradually, remits, or 
gets uniformly and progressively worse and more extensive, and 
after lasting for many years with the general health relatively unaf- 
fected, the patient dies of a different ailment, or rarely of pityriasis 
rubra pilaris itself when marasmus has developed. 

Differential Diagnosis. In generalized forms the confusion 
with pityriasis rubra of Hebra is such that the two conditions are 
indistinguishable, unless typical lesions of lichen acuminatus are 
found. In forms more or less localized the typical lesions, and 
particularly their localization on the dorsum of the fingers, facili- 
tate the recognition of the disease. The scaling plaques resemble 
psoriasis, but the scales and other characteristics of the latter ex- 
clude the likelihood of error in diagnosis. Lichen spinulosus is a 
rare follicular hyperkeratosis in which conical papules containing a 
spine two to three millimeters long are seen. Keratosis pilaris is 
common, and restricted usually to the backs of the arms and fronts 
of the thighs. Lichen planus, when its papules are perifollicular, 
closely simulates lichen acuminatus, but typical umbilicated papules 
and the greater frequency of the former condition, serve to exclude 
diagnostic error. The two diseases rarely coexist. 



THE LICHENS AND LICHENIFICATION 181 

Etiology and Pathogenesis. In Kaposi's early series of cases 
arsenic was so efficacious that the possibility of an infectious origin 
of the disease gained serious support. Nothing definite is known, 
however, substantiating any of the numerous hypotheses advanced to 
explain the pathogenesis of the malady. 

Treatment. This corresponds to that of lichen planus, although 
the disease may scarcely be called curable. 

Prognosis. As a rule the prognosis is good. Deaths, except- 
ing in Kaposi's original cases, are rare. 

Lichen Spinulosus (Devergie), also called keratosis follicularis spinosa 
and lichen pilaris (Crocker), is a rare condition chiefly seen in childhood, 
and involving the neck, buttocks, belly, thighs, popliteal spaces, and ex- 
tensor aspects of the arms. The lesions are conical papules containing a 
filliform, projecting plug or spine, about two millimeters long. The cause 
of the disease is unknown. Salicylic acid and tar salves cure it. It is 
probably no lichen, but a form of keratosis pilaris. 

Lichen Nitidus is a rare papular disease, occurring on the genitals, 
breasts, cubital fossa, palms, and abdomen. Clinically minute lichen planus 
papules are suggested, and microscopically giant cells and other features 
recall the picture of tuberculosis. 

LICHEN CHRONICUS ( SIMPLEX) OR BETTER PRIMARY LICHENIFICATION 

(FIG. 32) 

Synonyms. Neurodermite (Brocq and Jacquet) ; Prurit Cir- 
conscrit, or Prurit avec lichenification (Brocq) ; Lichen Chronicus 
Circumscriptus (Vidal) ; Eczema Papulosum (Hebra). 

Definition. Lichen chronicus circumscriptus is a circumscribed, 
itching, scaling, and more or less sharply circumscribed thickening 
of the skin, preceded by pruritus, and favoring certain definite 
localities and prone to recur. 

Symptoms. After a more or less prolonged period of itching, 
during which time no objective changes are present, the skin becomes 
pink or red, the color gradually growing more vivid. Then, flat, 
somewhat shiny papules arise, which increase in number until they 
are compactly grouped into plaques crossed by transecting furrows 
which are formed by the contiguous margins of the papules. Thus, 
a mosaic is built. When fully developed the plaque is five to 
fifteen centimeters in its greatest diameter, and in shape is oval 
or irregular. The favorite sites are the nape of the neck, elbow 
and knee flexures (Pig. 32), small of the back, scrotum, vulva, 
lower portion of the outer surface of the legs, thighs, crural folds, 
palms and soles ; but any part of the body is vulnerable. Single or 



182 DERMATOLOGY 

multiple patches, symmetrically or asymmetrically arranged, may be 
present. 

A fully developed plaque consists of three zones; an innermost, 
scaling, furrowed, infiltrated area, a second scaling, papular area, 
and an external or erythematous ring not more than three milli- 
meters broad. The lesions may itch intensely, grow warty, or be- 
come excoriated. Larger or diffiuse plaques of the same general 
nature may include great areas on the extremities, sides of the 
body, abdomen, upper part of the thorax, et cetera. These are almost 
always symmetrical. 

Course. Developing as described above, the lesions may increase 
in number, disappear spontaneously, remain away or recur, or they 
may persist indefinitely. 

Varieties. There are varieties determined by site, appearance, 
and accidents of development, but these are too many and of too 
little importance for enumeration. 

Differential Diagnosis. But three conditions simulate lichen 
simplex — psoriasis, lichen planus and secondary lichenification. 
The silver scales of psoriasis, the absence of furrows, the less marked 
infiltration, preference for the extensor surfaces, involvement of 
the scalp, and usually other typical lesions of the disease point out 
the probability of psoriasis. Lichen planus, unless typical papules 
and mucous lesions are present, is indistinguishable from lichen 
simplex. Secondary lichenification closely simulates primary, but 
it arises as a sequela of some pre-existing dermatosis, and thus its 
recognition is always simple. This question will again be dis- 
cussed below. 

Etiology and Pathogenesis. Very little definite knowledge of 
the origin of the disease exists. It is commoner among women than 
men, is associated with all sorts of metabolic disturbances, and fre- 
quently develops after psychic or emotional strains. Every explana- 
tion has been furnished that it is customary to advance in lieu of 
conclusive evidence. 

Treatment. This corresponds exactly to the treatment of 
chronic psoriasis (Chapter XI). The Kromayer lamp is of great 
value. 

Prognosis. In general, the plaques are amenable to therapy. 
Recurrences are likely. When a high degree of infiltration is 
present, the patches may be intractable. The general health is 
never affected. 




Fig. 27. LICHEN PLANUS 

Examples are here shown of all types of lesions. The 
umbilications show distinctly, below the wrist and over the 
middle metacarpals. Near the rings are seen tiny fresh 
lesions. The lesions are elevated, polygonal and steep sided. 




Fig. 28. LICHEN PLANUS OF THE MOUTH 

Near the tip of the tongue are minute polygonal papules. Over the dorsum 
the lesions have coalesced into a plaque. There are papules and patches on the 
lips. All are shining and white. Syphilitic and non-specific leucoplacia are 
simulated, but in these conditions there are no distinct papules. Lupus eryth- 
ematosus sometimes involves the lips, but its color is less snowy, and there is 
either more exudation or more atrophy than in lichen. 




Fig. 29. LICHEN PLANUS ANNULARIS 

^ This form may appear anywhere on the body, but is most frequently 
situated on the glans. A lavender ring of papules forms, some of 
which are umbilicated, and nearby lie isolated papules, as shown in 
the picture. The infiltration at times suggests that of syphilis, the 
annular forms of which are sometimes imitated so closely as to defy 
diagnosis, save that the specific forms do not itch, and are buff rather 
than purple. 




WARTY 



This form may occur at other sites, but it favors the shins over the shoe-tops. 
It consists of warty, or at least raised, scaly, purple patches, composed of coa- 
lesced papules, the contiguous margins of which survive and remain separated by 
narrow linear furrows. Thus a curious cross-hatching arises, quite distinctive, 
and clearly indicated in the picture. Nearby there are often isolated papules. 
Lichen simplex, hypertrophic dermatitis, or thickened psoriasis may be simu- 
lated, and differentiation is sometimes impossible without discovery of pure le- 
sions typical of the different diseases. 




Fig. 31. LICHEN ACUMINATUS OR PITYRIASIS 
RUBRA PILARIS 
Characteristic follicular papules are on the forearms. 
The wrist is lichenified, and the palm, tylotic. These fea- 
tures are distinctive. 




Fig. 32. NEURODERMITE 

This condition is also called lichen simplex, pri- 
mary lichenification or pruritis with lichenification. 
Its favorite sites are the popliteal and cubital 
bends, the small of the back and nape of the neck. 
It consists of thickening which is brown, buff or red 
and the area is traversed by the natural markings 
of the skin, exaggerated. Often scratched papules 
are studded over the affected surface. 



THE LICHENS AND LICHENIFICATION 183 

SECONDARY LICHENIFICATION 

This is a thickening of the skin arising in the course of itching 
dermatoses such as chronic dermatitis, prurigo, chronic urticaria 
and dermatitis herpetiformis. The appearance of the plaques is 
identical with that of those arising in primary lichenification. Their 
diagnosis rests upon their association with a preceding dermatosis. 
It is this form of lichenification which Hebra called papular eczema, 
because papular eczemas resemble it, and this was responsible for 
the confusion that has long existed in our conception of the relation 
of primary to secondary lichenification. The treatment and progno- 
sis of the disease are determined by the nature of the underlying 
cutaneous affection. 



GKOUP IV. EPIDERMAL DYSTROPHIES AND 
HYPERKERATOSES 

This group is complex to define. The epidermal dystrophies all 
possess the common attribute of peculiar epidermal inclusions orig- 
inally regarded as pathogenic organisms, and which since have been 
found to be altered or perhaps degenerated rete cells incapable of 
complete keratinization, that is, of fully maturing. The process in 
question is termed dyskeratosis, and the cells in question are called 
dyskeratotic. At least one of these, the molluscum body of mollus- 
cum contagiosum, which is an infectious disease, must contain the 
pathogenic agent, although it has until now eluded identification. 
Verruca plana is also probably infectious, but presents no structure 
similar to that observed in molluscum, nor is the microscopic archi- 
tecture of the lesion suggestive of any close kinship with the latter. 
On the contrary, its histology is like that of the common wart, 
or verruca vulgaris, namely an epithelial proliferation. It must 
be remembered though that molluscum is likewise due to such a 
proliferation, and one of the names of this disease is epithelioma 
molluscum. 

The other dyskeratoses are psorospermosis, or Darier's disease, 
containing psorosperms which are only large degenerated epithelial 
cells, condyloma acuminatum containing the curious X-cell first 
noted by Unna ; Bowen's precancerous dermatosis and Paget's disease 
of the nipple, both characterized by the presence of changed epider- 
mal cells similar to those observed in psorospermosis. 

The hyperkeratoses are noteworthy for the fact that without 
marked inflammation in the cutis the epidermis proliferates either 
within or without the follicles or both. A great number of clinical 
pictures results from this process. Whether the disease is congeni- 
tal or acquired, an anomaly or the result of trauma, a familial or 
merely congenital disease, or one caused by some internal disturb- 
ance, the salient clinical feature is a hyperkeratotic plug, scale, or a 
combination of these; the salient histological feature is a thickening 
of the epidermis mainly due to hyperplasia of the corneous layer. 



184 



CHAPTEK XIV 

EPIDERMAL DYSTROPHIES; DYSKERATOSES 

The diseases of this class are molluscum contagiosum which is in- 
fectious, psorospermosis, condyloma acuminatum, Bo-wen' s precan- 
cerous dermatosis and Paget's disease. Verruca plana may per- 
haps belong here too, but since its only claim to such classification 
is its probable infectiousness, and since microscopically it resembles 
the ordinary wart, it will be described with the benign epithelial 
neoplasms. Molluscum contagiosum and condyloma acuminatum 
are common diseases ; the others are comparatively infrequent. 

MOLLUSCUM CONTAGIOSUM (FIG. 33) 

Synonyms. Epithelioma contagiosum, Epithelioma molluscum. 
(There are other synonyms which have fallen into disuse and hence 
will be omitted.) 

Definition. Molluscum contagiosum is a small cutaneous tumor, 
evidently infectious, not serious, incapable of spontaneous involu- 
tion and easily removed. The tumors may be single or multiple 
and are at times numerous. 

Symptoms. The tumors average the size of a pea, are pink, 
flesh-colored or whitish, rounded, sessile, but often slightly con- 
stricted at the base, and are pierced by a central aperture (Eig. 33). 
When compressed, a glistening waxy mass is extruded. The tumors 
may occur anywhere on the body, but the face, eyelids, nose, scrotum, 
labia, breasts and backs of the hands are the favored sites. At 
times infection takes place converting the mass into an abscess. 
There are no subjective symptoms. 

Course. The lesions develop suddenly or gradually, and one 
lesion may persist for years, or they may become countless in num- 
ber and vary in size. Extremely large ones, the size of an egg in 
fact, have been reported, but this is exceptional. 

Pathology. 1 Histologically the lesions suggest the structure of 
a pomegranate. They are septate and consist of epidermal wedges 
containing rounded, enlarged structures, the molluscum bodies, 

i This is of diagnostic importance. 

185 



186 DERMATOLOGY 

which fit into the segments as do the seeds in the above mentioned 
fruit. The picture is pathognomonic. 

Differential Diagnosis. Warts resemble molluscum contagi- 
osum but contain no waxy mass. An infected molluscum looks like 
a furuncle or suppurating sebaceous cyst, and often cannot be rec- 
ognized unless the characteristic waxv contents are found, or a 
microscopic study of the lesion is made. Eyelid molluscum often 
resembles the ordinary stye and a diagnosis is reached only as 
outlined in the previous sentence. To confuse molluscum with 
variola, or when it is on the genitalia with syphilitic chancre, is 
virtually impossible, and although the average text-book discusses 
these points, the matter is too absurd for consideration. 

Etiology and Pathogenesis. The facts that a mother's breast 
may be infected by a nursing baby suffering with molluscum, and 
experimental evidence indicating its transmissibility, prove its infec- 
tious origin. The micro-organism has not yet been isolated, al- 
though Wile has isolated a filtrable virus which he thinks produces 
the local changes in the rete causing the molluscum bodies. 

Treatment. The only rational treatment is the removal of the 
lesions by expression, with or without previous incision, curettage 
or puncture. The method employed is determined by the site, size 
and number of the lesions. 

Prognosis. The disease is always curable and relapses are rare. 

PSOROSPERMOSIS (fig. 34) 

Synonyms. Darier's disease; Psorospermosis follicularis vege- 
tans; Keratosis follicularis; Keratosis vegetans. 

Definition. Psorospermosis is a rare, probably familial disease 
the characteristic clinical features of which are follicular plugs 
and perifollicular papules, red, brown, or purple in color, fairly 
definitely localized, capable of proliferating and becoming crusted, 
ulcerated or vegetative. The anatomic structure is distinctive, in- 
dicating that the malady depends upon a disturbance of the normal 
maturing of the epidermis. 

Symptoms. The lesions first appear on the head and face. 
Then the extremities, front of the thorax, groins, genitalia and 
flanks are involved. Punctate, follicular flesh-colored papules are 
the earliest lesions observed. These grow, becoming red, brown or 
purple and develop into crusted, ulcerating or papillomatous masses 
which in the body folds are macerated and may emit an offensive 
odor. The distribution of the efflorescences on the face is fairly 



EPIDERMAL DYSTROPHIES; DYSKERATOSES 187 

typical, the scalp, temples and nasolabial folds being first involved. 
As the papules grow the plugs they contain darken and look some- 
thing like a blackhead, but are hard, not fatty, and difficult to 
express from the follicular openings. A hyperkeratosis arises on 
the palms, soles and backs of the hands, depending primarily upon 
the papules. Under the nails there is epidermal proliferation. 

Course. Beginning gradually in adult life the disease pro- 
gresses steadily, does not diminish the general health, and except 
for slight itching, causes no annoyance. Wende reported a unique 
case in which epithelioma developed. 

Differential Diagnosis. Keratosis follicularis contagiosa of 
Brooke and acanthosis nigricans almost duplicate the clinical ap- 
pearance of psorospermosis. The history, in the former, and the 
presence of a visceral cancer in the latter, as will be further em- 
phasized below, exclude the likelihood of diagnostic error. Lichen 
acuminatum in its earlier stages resembles psorospermosis, but it 
never vegetates. A microscopic study is always of aid in recog- 
nizing the disease, since the structure of the lesions is characteristic. 
A follicular plug of corneous cells, and the presence of enlarged, 
round bodies, the corps rondes, or psorosperms, with the lack of 
marked alteration elsewhere, are distinctive. 

Etiology and Pathogenesis. Nothing is known of the cause 
of the malady save that it frequently appears in many generations 
of the same family. The infectious theory of its origin has been 
abandoned, through lack of substantiation, and the psorosperms 
have long since ceased to be considered pathogenic organisms. 

Treatment. Salicylic acid, salves and pastes and Eoentgen 
therapy have caused amelioration, but no cures of the disease. 

Prognosis. The disease is harmless, but incurable. 

CONDYLOMA ACUMINATUM (FIG. 35) 

Synonyms. Verruca Acuminata; Venereal Wart; Fig- wart; 
German, Spitzencondylom ; French, Cretes de Coq. 

Definition. Acuminate condylomas are papillary excrescences 
developing upon the genital mucosa and contiguous surfaces. They 
may be single or multiple, or so numerous as to be compactly 
crowded. Secretion with crusting may form, and the entire mass 
may ulcerate and become fetid. The glans, prepuce, introitus and 
anus are the most commonly affected sites. The lesions are bright 
red on the mucous membrane and soft to the touch. When the 
neighboring skin is affected, the color is paler and the consistency 



188 DERMATOLOGY 

firmer. They resemble filiform projections, or are shaped like a 
cock's comb, or are delicately tufted. 

Course. They rarely disappear spontaneously, but start gradu- 
ally or suddenly and increase in number. 

Diagnosis. When single they cannot be differentiated from 
papillomatous warts. When multiple their appearance is distinc- 
tive. Histologically, the epidermal cells are found to be large and 
have a clear space where the cytoplasm is degenerated. The nuclei 
are crescent shaped and excentric. These are the so-called X-Cells 
of TJnna and were originally regarded as pathognomonic of the 
disease. Although this is not entirely true, there is no condition in 
which they are so numerous as in condyloma acuminatum, and this 
fact may serve as a diagnostic aid. 

Etiology and Pathogenesis. They are precipitated by irritat- 
ing secretions, leucorrhoea, balanitis, gonorrhoeal pus, discharges in- 
cident to pregnacy, et cetera, and are infectious, although the path- 
ogenic organism is still unkonwn. They are not gonorrhoeal in 
origin as was once supposed. Gonorrhoeal discharge is but one of 
the elements favoring their development. They are auto-inocula- 
ble but not transmissible from one individual to another. 

Treatment. They must be removed mechanically, either by the 
curette or high frequency spark. As the parts affected are highly 
sensitive, local or general anesthesia is necessary, according to the 
site and extent of the lesions. After their removal, antiseptic 
dusting powders must be used to prevent infection, or if the surface 
treated is extensive, large, antiseptic dressings must be applied. 
When the disease occurs in gravidae there is no sense in starting 
treatment until after the confinement, as recurrences are inevitable. 
It is necessary, however, in order to minimize the danger of puer- 
peral infection, to treat the parts with mild antiseptics, and to cleanse 
them even more thoroughly than usual at the time of the delivery. 
At times involution may be caused by powdering with equal parts of 
alum and calomel. 

Prognosis. The condition is invariably curable. 

Verruca Plana Juvenilis (Fig. 36) are flat warts mentioned here because 
they share with molluscum and pointed condylomas the characteristics of in- 
fectiousness. They are, however, not dyskeratoses, but hyperkeratoses, and 
will be described in detail with the benign epithelial neoplasms. (Chapter 
XXVII.) They too, according to Wile, are due to a filtrable virus. 

Bowen's Precancerous Dermatosis (Fig. 37) is a dyskeratotic condition 
closely related to the senile wart. It is included here to complete the classi- 
fication of dyskeratoses, for microscopically there are corps rondes as in 



Fig. 33. MOLLUSCUM CONTAGIOSUM 

In this disease, small yellow, pink or red papules or nodules arise, mainly 
on the face but also elsewhere. A small pore or depression is found in the 
center; and on pressure, a white, waxy glistening mass may be forced out, 
which microscopically shows molluscum bodies. Clinically, the disease can 
scarcely be confused with anything else. 




Fig. 34. KERATOSIS FOLLICULARIS CONTAGIOSA 

This disease is called Darier's disease and psorospermosis, a term now ob- 
solete. This is a classical picture. The lesions are small, brown, follicular, 
conical papules which first appear in the body folds and then become gener- 
alized, forming large patches covering great areas. Only acanthosis nigri- 
cans, a still rarer disease, is remotely simulated. The latter is associated 
with visceral malignancy. Dariers disease has a fairly characteristic his- 
tology, peculiar rounded bodies being present in the epidermis near the 
follicles. 




Fig. 35. 



CONDYLOMA ACUMINATUM OR V-ERUCCA ACU- 
MINATA 



This is a papilloma of the genitalia, and may occur anywhere on these 
organs. The lesions are pointed, fleshy, red, brown or purplish, pointed 
papillomata. 




Fig. 36. VEKUCCA PLANA JUVENILIS 

The face and back of the hands are covered with minute waxy, yellowish, 
glistening papules. In this patient, only the facial lesions are shown. 
There is no inflammation, but from a distance at times, milia- crystallina, 
or early lichen are suggested. The former is excluded by puncturing the 
lesions. In milia fluid would exude. The latter is excluded by the rarity 
of lichen in children, and the great rarity, at any age, of facial lichen; to 
say nothing of other evidence of the latter such as itching, mucus, involve- 
ment, etc. 












Fig. 



37. KERATOSIS SENILIS, OR SENILE OR SEBOR- 
RHOEAL WART 



This is found on the face, back or chest of the elderly or aged. 
The lesions are flat or slightly raised, circular, oval or somewhat 
irregular in outline, and covered by a scale that is yellow, buff 
or grajr, brown or black, and hard, rough and dry. At times such 
lesions give rise to epitheliomata and are closely related to 
Bowen's precancerous dermatosis. When grouped, they may re- 
semble tuberous gummata and the Wassermann test or a histologi- 
cal examination may be required to make the diagnosis. 



EPIDEKMAL DYSTROPHIES; DYSKEKATOSES 189 

psorospermosis. It will be described in detail in connection with senile 
hyperkeratoses and verrucae (Chapter XXIX), and its relation to epitheli- 
oma will be discussed in this connection and in the chapter on cutaneous 
cancer. 

Paget's Disease, both mammary and extramammary, also contains psoros- 
perms, but the disease will be referred to more completely in the discus- 
sion of the classes of epithelioma. (Chapter XXIX.) 



CHAPTEK XV 

HYPERKERATOSES 

The hyperkeratoses are varied in their appearance and causation. 
Their common bond lies in the fact that they all possess a thickened 
stratum corneum. They may be classified as follows: 



Hereditary : 



Congenital : 

Congenital Gain- 
ing Expression 
in Adult Life : 

Pure Follicular 
Hyperkeratoses : 

Infectious : 
Metabolic : 

Traumatic : 



Regressive : 



Unknown Origin : - 



{Keratosis palmar is et plantar is (Mai de 
| Meleda) 

Keratosis exfoliativa congenita 
Ichthyosis (probably a Naevus — Chapter 
XXXII) 

Keratosis pilaris 

Lichen spinulosus (Chapter XIII.) 
Ulerythema ophryogenes 
Lupus Erythematosus (possibly a tubercu- 
lide — Chapter XXV) 

| Keratosis follicularis contagiosa 

j Acanthosis nigricans 

f Callus 
[ Clavus 

Keratosis senilis (see Seborrhoea — Chap- 
ter XI and Epithelioma — Chapter 
XXVIII) 

Cornu cutaneum (see Epithelioma — Chap- 
ter XXVIII) 
Porokeratosis. 



Clinically, these diseases are characterized by a thickening of 
the corneous layer causing either sessile, solid elevations as in corns, 

190 



HYPERKERATOSES 191 

calluses, horns and palmar keratoses; follicular hyperkeratoses with 
plugs as in keratosis pilaris, lichen spinulosus, ulerythema 
ophryogenes, lupus erythematosus, keratosis follicularis contagiosa 
and acanthosis nigricans; or scaling as in ichthyosis, keratosis 
exfoliativa congenita, lupus erythematosus, and porokeratosis; 
atrophy as in keratosis pilaris, ulerythema ophryogenes and lupus 
erythematosus; or some combination of these features as is obvious 
from the above, and as will be further indicated in the ensuing. 
The majority of these diseases cause no subjective symptoms. 
Many of the diseases are rare; those of practical significance are 
ichthyosis, keratosis pilaris, lupus erythematosus, callus, clavus, 
keratosis senilis, cornu cutaneum. The less usual ones will receive 
scant mention and this only for the sake of completeness. Lichen 
spinulosus has already been described (Chapter XIII). 

ICHTHYOSIS 

Synonyms. Fishskin Disease. 

Definition. Ichthyosis is a congenital skin anomaly character- 
ized by dryness, harshness and scaling. There are three commoner 
types of the disease, ichthyosis simplex, hystrix, congenita, and two 
rare forms, ichthyosis follicularis and erythroderma congenital is 
ichthyosiforme. 

Symptoms. Ichthyosis simplex is the mildest form. The skin 
is rough, dry, impliable, covered with furfuraceous scales. The des- 
quamation is fine or flaky, and the extensor surfaces of the extremi- 
ties may be involved alone, or the entire body may participate in 
the process. The color ranges from the normal flesh tones to a dirty 
gray or brown. Although the disease is congenital, its first mani- 
festations appear at the seventh or eighth week and increases in 
severity with years. During the summer it often improves or dis- 
appears entirely, getting worse in winter. Xerosis is another name 
for this mild type, which may persist throughout life, and grow 
gradually worse constituting a so-called xeroderma, which must not 
be confused with xeroderma pigmentosum. Severer forms closely 
resemble reptilian skins and are called sauriasis. In the fish skin 
and reptilian or alligator skin forms the scales look like those seen 
on the animals in question and are separated from each other by 
depressions. 

Ichthyosis hystrix is a form in which are present scales and 
patches with spinous projections arising from papules or verrucoid 
areas. In this form the lesions occur in circumscribed islands, 



192 DERMATOLOGY 

linear, plaque-shaped or irregularly outlined. They closely resem- 
ble hyperkeratotic naevi which they probably are. This view is 
widely accepted and appears logical if the question of naevi is 
approached with breadth of view. 

Ichthyosis congenita is rare. It is also called keratosis univer- 
salis congenita. There are two varieties; one always fatal, the other 
often mild. The former is peculiar in that the fetus appears as 
if covered by a coat of mail. The face looks mummified, and the 
digits resemble claws rather than fingers and toes. The milder form 
presents a papyrus-like skin which after a few days splits into 
large scales, under which there is a normal integument. These 
cases recover, or develop a mild form of ichthyosis which persists. 

Ichthyosis follicularis is rare. There are only three cases reported. 
Erythrodermie congenitale ichthyosiforme of Brocq is a congenital malady- 
resembling ichthyosis, but the skin is red as though inflamed. It is usually 
seen only about the face, neck, body folds, flexor surfaces ; associated sebor- 
rhoea of the scalp is usually observed and the general health remains good. 

Course. Simple ichthyosis appears two months after birth, im- 
proves in the summer, is augmented in the winter, and either stays 
unchanged throughout life, or gets worse at puberty, remaining un- 
changed after this period. Ichthyosis hystrix, follicularis and con- 
genital ichthyosiform erythroderma never change. Only one form, 
as noted above, is fatal, or the amicted individual is born dead, and 
this is the malignant type of congenital ichthyosis. 

Varieties. These have been enumerated in the description of 
the disease. 

Differential Diagnosis. Except in ichthyosis hystrix, which 
those who exclude it from naevi would have to differentiate from 
the latter, the picture is so characteristic that no other condition is 
to be considered. 

Etiology and Pathogenesis. Barring the certainty of its being 
a congenital and in some cases an hereditary anomaly, nothing is 
known of its causation. 

Treatment. Oils, fats, and X-Kays are employed and occa- 
sionally a cure is effected. Salicylic acid may be incorporated into 
the oils up to five percent, and daily inunctions given. This simply 
serves to increase the pliability of the skin. Eucerin and cold 
cream are valuable, and divided doses of X-R,ays are particularly to 
be recommended. Ichthyosis hystrix responds best to carbon 
dioxide snow, massive doses of X-Rays and it is probable that radium 
will prove to be of great value. 



HYPERKEKATOSES 193 

Prognosis. The disease is rarely curable and equally rarely 
harmful. 

KERATOSIS PILAEIS 

Synonyms. Keratosis suprafollicularis (Unna) ; Lichen pilaris; 
Pityriasis pilaris. Probably Unna's designation is the most accu- 
rate as the chief anatomical changes are found high in the follicle. 

Definition. Keratosis pilaris is a hyperkeratosis causing the 
formation of a horny plug in the upper third of the pilosebaceous 
follicle. About the affected ducts a red or white papule arises. 

Symptoms. The disease is common and consists of perifollicular 
papules surmounted by horny plugs filling the mouths of the affected 
organs. The plugs are short, white, gray, or dark, often contain an 
atrophied hair which may be curled up or project slightly, and the 
sites usually affected are the extensor aspects of the limbs, the thighs, 
and even the shoulders. Occasionally, the face is involved. The 
papules are white or red, and the involved skin feels rough. The 
depth of the red varies from pink to purple, according to the 
degree of vascular dilatation present. 

Course. The disease sometimes appears in childhood, more fre- 
quently at puberty, and thereafter persists throughout life, tending, 
however, to decrease after the third decade. In disappearing, it 
leaves atrophic spots causing a slight wrinkling of the skin at the 
site of the former papules. 

Varieties. Keratosis pilaris alba and rubra are the only two 
known types. 

Differential Diagnosis. Only lichen acuminatus and lichen 
spinulosus resemble keratosis pilaris. The history, onset, common- 
ness of the disease, its typical localization and absence from the 
fingers, differentiate it from lichen acuminatus. From lichen spin- 
ulosus it is distinguished by the lack of spines. 

Etiology and Pathogenesis. Puberty is one element in its 
causation. This brings it into direct connection with changes in the 
endocrinous glands. By many it is regarded as a form of ichthy- 
osis. It is so common — in fact, few individuals fail to present a 
mild form of it — that it must be hereditary in the broadest sense. 
Uncleanliness is regarded as a cause. This is absurd, although fre- 
quent bathing reduces the intensity of the symptoms by removing 
the plugs. 

Treatment. This corresponds to that of ichthyosis. 

Prognosis. The disease is harmless but in general incurable, 
although its extreme manifestations may be ameliorated. 



194 DEKMATOLOGY 

Lupus Erythematosus. This disease will be taken up in detail in Chap- 
ter XXV. One of its features, however, the presence of horny plugs at 
the bottom of its scales, indicates a certain relationship to the hyperkera- 
toses. It is only its possible tuberculous origin, and the fact that it ap- 
pears in non-keratotic forms, that make it advisable not to include it too 
arbitrarily in the hyperkeratoses. 

CALLUS 

Synonyms. Callositas; Tylosis; Keratoma; German, Schwiele. 

Definition. Callosities are circumscribed, thick, horny patches 
of epidermis, usually due to pressure, and found as a rule on the 
palms and soles. 

Symptoms. The appearance of these lesions is so well-known 
that a description is unnecessary. Unless they become infected, or 
unless the pressure which provokes them is not properly relieved 
from time to time, they do not hurt. 

Course. While the exciting condition obtains they persist. 

Diagnosis. They must he differentiated from keratosis palmaris 
et plantaris hereditaria and arsenical keratoma. This is always 
easy if a careful history is taken. 

Etiology and Pathogenesis. The lesions result from the pres- 
sure of ill-fitting shoes, various occupations, such as metal working, 
the playing of certain instruments, notably the banjo and harp, 
and even the piano. Thus, the site of a callosity often indicates the 
nature of the patient's work. 

Treatment. Applications of salicylic acid plaster, ten to twenty- 
five percent., or salicylic acid in collodion are the best methods of 
treatment. Surgical removal, or the use of the high frequency 
spark, is often indicated. The only rational therapy is the elimina- 
tion of the exciting cause. The Roentgen rays are often of great 
value. 

CLAVUS 

Otherwise known as Corn. 

It is unnecessary to enter into details concerning this common 
affection. 

KERATOSIS SENILIS (FIG. 37) 

In the aged the face, chest and back become covered with papules 
possessing a hyperkeratotic scale, gray or brown in color. These 
lesions vary in size up to that of a dime and are often one-eighth 
inch high. They are greasy, look like flat warts, and are often 
called senile warts. Many authors include them among precan- 



HYPERKERATOSES 195 

cerous dermatoses, a point which will be discussed in the etiology 
of epithelioma. (Chapter XXIX.) They are readily cured by 
sulphur salves, and five to ten percent, salicylic acid plaster. 
They occur anywhere that seborrhoea occurs and are distinctly 
related to senility. 

CORNTT CTJTANEUM 

Cutaneous horn, is a rare hyperkeratosis which may be small 
or large, and roughly simulates horns as seen in lower animals. 
The growth may be straight, conical, twisted, or irregular in shape or 
size. Usually the lesions are single, rarely multiple and their fa- 
vorite sites are the scalp, brow, temples, nose, penis, and finally any- 
where else on the body or face. Their cause is similar to that of 
senile keratoma, but they often spring from scars of lupus vulgaris, 
burns, or cicatrices resulting from strong acids and alkalies. At 
times epithelioma develops at the base. The treatment consists of 
excision, and if epithelioma is present, of massive doses of X-Rays 
to the scar resulting from the operation. 

KERATOMA PAEMARIS ET PLANTARIS 

Synonyms. Keratoderma palmaris et plantaris; Congenital palmar and 
plantar keratosis; ichthyosis or tylosis of the palms and soles; Mai de 
Meleda. 

Definition. The disease is a familial, often hereditary callosity of the 
palms and soles, one form of which is indigenous to the Dalmatian Island 
of Meleda. 

Symptoms. The palms and soles are thickened as to their epiderm. 
They are thus covered by a horny plate which is smooth yellow, unless it 
becomes soiled by work, when the surface is gray, brown or black, pitted, 
fissured or verrucous. At the margin of the lesion the normal skin appears 
abruptly. 

Course. The disease is permanent. 

Varieties. There are two varieties, the acquired and hereditary which 
may be congenital, or appear long after birth. Mai de Meleda belongs to 
the second group. 

Differential Diagnosis. The true palmar and plantar keratoma must be 
differentiated from the hyperkeratosis developing at these sites in chronic 
dermatitis, syphilis, lichen planus and acuminatus, arsenical keratosis, 
callus, and rarely in psoriasis. Other evidences of the first four diseases 
clear up the differential points involved in their recognition. The history 
is the determining factor in recognizing arsenical keratosis. Trauma and 
occupation are the determining factors in diagnosticating callosities. 
Palmar and plantar psoriasis are so rare that it is useless to dwell upon it. 

Treatment. In the acquired forms the removal of the predisposing cause 



196 DERMATOLOGY 

will often produce healing as in callosities. The familial varieties are 
incurable. X-rays may be tried and often produce improvement. 
Prognosis. This depends upon the cause. 

Keratosis Follicularis Contagiosa (Brooke'). 

This rare condition arises in children, on the neck, face, shoulders, and 
extensors of the upper extremities. It somewhat suggests psorospermosis, 
is infectious, and easily cured by mercurial antiseptics, particularly the 
iodine salts applied locally. 

Porokeratosis of Mibelli and Bespighi is very rare. Its main character- 
istic is a prismatic wall encircling a normal, atrophied or hypertrophied 
basin. From the inner aspect of the wall a fine scale projects toward the 
basin, and this scale resembles a collar. The summit of the wall is de- 
pressed into a gutter. The disease cannot be cured. It affects the extrem- 
ities, particularly the hands and feet, more than any other part of the body. 

Acanthosis Nigricans, keratosis nigricans, or dystrophic papillaire et 
pigmentaire of the French, was first described by Sigmund Pollitzer. The 
disease is rare, occurs in the body folds, chiefly the axillae, groins, inner 
sides of the thighs, bends of the elbows and knees, on the belly, forearms, 
perineal region, face, umbilicus, scrotum and about the anus, although the 
entire skin may be covered. The color of the lesions varies from yellow 
or brown to black, and tubercles, papillomas, or vegetating masses are seen. 
The tumors are sessile or pedunculated, and frequently all sorts of warty 
or nevoid lesions co-exist. An adult variety is known associated with 
visceral malignancy, and a second variety of which the causation is not 
understood. The therapy is usually ineffective and the prognosis always 
grave, although some cases improve when the visceral tumor is removed. 
Local therapy with oils, salves and plasters is of slight benefit. 

Keratosis Exfoliative Congenita. This is a rare exfoliative congenital 
dermatosis, probably related to ichthyosis and allied with the still rarer 
ichthyosis rubra of Rasch. The condition is so uncommon that, for prac- 
tical purposes, it requires scant mention. 



GKOUP V. DYSTROPHIES OF THE SKIN AS A WHOLE 

This class of diseases includes four sub-groups, hypertrophies of 
the connective tissue, atrophies of the connective tissue, pigmentary 
diseases, and finally, degenerations. Save for the general fact that 
all of the conditions here included are basically alterations in the 
collagen or elastic tissue, if not both, there is no striking relation- 
ship among the groups. Collagenous and elastic tissues, the blood 
and lymph vessels therein imbedded, the pilosebaceous and sweat 
structures, and the arrector muscles, form a background for a great 
variety of changes, and respond variously to diverse pathogenic 
forces. 

CHAPTEE XVI 

HYPERTROPHIES OF THE CONNECTIVE TISSUE 

Three common and six rare diseases constitute this series, and 
another condition, paraffin prosthesis, due to the presence of a foreign 
body exciting a fibrosis, must here be mentioned. The pathology 
of the last named is determined by the attempt of the body to 
guard itself against an alien substance. The common conditions 
are the scar, keloid and elephantiasis; the rarer ones are sclerema 
neonatorum, edema neonatorum, hereditary edema of the legs, 
acromegaly, myxedema and cutis verticis gyrata. 

scab 

Synonyms. Cicatrix; German, Narbe; French, cicatrice. 

Definition. A scar is the result of the reparative process fol- 
lowing an injury to the skin involving at least the papillary body, 
if not deeper levels. It is composed of fibrous connective tissue. 

Symptoms. Scars may be normally, excessively, or subnormally 
sensitive, or even insensible. Pain may be spontaneous, or elicited 
only by touch. To the eye the lesions may be flush with the skin, 
depressed, raised, or have a raised margin and a depressed centre. 
Some cicatrices are markedly raised, and these are known as hyper- 
trophic or keloid scars. In shape and size they vary according 
to the determining injury, and their depth depends upon whether 

197 



198 DERMATOLOGY 

the papillary body or still deeper levels have been destroyed. Their 
color varies; fresh scars are red or blue because they are rich in 
vessels ; older ones tend to be white. Some have the normal flesh 
tint, others are depigmented, others are pigmented, and still others 
have white centres and brown rims. Usually they are movable; 
occasionally fixed to the deeper tissues. 

Scars resulting from syphilis tend to be white within and brown 
at the margin; they are crinkly and thin, reniform, fan-shaped, 
circular or oval, single or grouped according to the lesions producing 
them. Scars resulting from tuberculosis, particularly those fol- 
lowing lupus vulgaris, are white, redundant, corded and irregular in 
outline. Scrofula produces cicatrices fixed to the deeper tissues. 
Zoster causes grouped, small, pitted cicatrices at the site of dis- 
tribution of the original eruption. Variola, varicella, acne vario- 
liformis and the tuberculides produce small pits, no larger than a 
bean with deep, steep sides and a white base. Morphine addicts 
have similar scars from infected hypodermatic injections. The 
only free areas are those inaccessible to the patient's hands. This 
fact makes the picture characteristic. Ecthyma and vaccination 
form white, pliable cicatrices, often cribriform because they are so 
superficial that the follicles are not destroyed. Acne forms irregu- 
lar, small pitted scars. Cicatrices due to trauma, surgery, acids, 
caustics, burns, et cetera, vary in size, shape, contour and color and 
other attributes, according to the nature of the injury. The possi- 
bilities are so numerous and the pictures presented so well-known 
that further description is unnecessary. 

Varieties. Scars are atrophic, hypertrophic, pigmented or de- 
pigmented, as mentioned above. 

Differential Diagnosis. There is no difficulty in recognizing 
cicatrices. 

Etiology and Pathogenesis. This is obvious. 

Treatment. Only excision, either with or without skin graft- 
ing, is of avail. 

Prognosis. Scars are permanent. 

keloid (fig. 38) 

Synonyms. Kelis; Cheloid. 

Definition. A keloid is a connective tissue hypertrophy, irregu- 
lar or regular in shape, usually presenting dentritic or fan-like 
proliferations, and in its true form arising spontaneously. It is 
more common among negroes than whites. 



HYPEKTROPHIES OF THE CONNECTIVE TISSUE 199 

Symptoms. Keloids start as nodules which progress becoming 
ribbon or strand-like, fan-shaped, arborescent, or irregular in out- 
line. They are hard, raised, pink or red, if vascular; white or 
brown, according to their pigment content, and they may or may 
not be painful or tender. Any part of the body may be affected, 
but the chest, face and neck most frequently are, and of these chiefly 
the first, over the sternum. The lesions may be single or multiple 
and in the latter eventuality a dozen or more may be present. 

Course. The disease usually begins in adult life and develops 
slowly, progression being gradual but inexorable. 

Varieties. There are two varieties, the true or spontaneous ke- 
loids which are fibromata (Chapter XXX), and the false or 
spurious which are hypertrophic cicatrices (see above), resulting 
from injury or disease. 

Differential Diagnosis. The appearance is typical and the diag- 
nosis is made upon this point. 

Etiology and Pathogenesis. This is unknown, but race or 
heredity must have some bearing on their causation, since the disease 
is so much commoner among negroes than among other people. 
Probably true keloids are fibromata. 

Treatment. Fibrolysin and thiosinamin have been used, on the 
whole without favorable results. Roentgen (four Holzknecht units 
repeated once or twice at intervals of a month) and radium therapy 
are successful very often. Excision, cauterization, et cetera, are 
useless, as recurrences almost invariably take place. 

Prognosis. On the whole the prognosis is bad because of the 
tendency toward recurrence even though therapy may be successful 
with reference to given lesions. 

ELEPHANTIASIS 

Synonyms. Elephant, Barbados or Cochin Leg; Pachydermia; 
Elephantiasis Arabum; Hypersarcosis. 

Definition. Elephantiasis is a chronic cutaneous and subcuta- 
neous hypertrophy and hyperplasia, usually secondary to obstruc- 
tion of the lymphatics. 

Symptoms. The organs most frequently diseased are the lower 
extremities, genitalia, upper extremities, lips, ears, or other parts of 
the face. Any part of the body, however, may be affected. At first 
the skin is tense, white and thickened; then these characteristics be- 
come augmented, and gradually warty, scaling, pigmentation, with 
atrophy or hypertrophy of the skin organs, develop. The hair and 



200 DERMATOLOGY 

nails become brittle and discolored, or fall off. There is pit- 
ting on pressure and often painful lymphangitis exists. In later 
stages secondary dermatitis, ichthyotic changes, marked verrucosities, 
fissures, furrows, deep pigmentation appear and secretions and 
detritus accumulate. When extreme the enlargements are huge, 
the leg becoming elephantine, the genitalia enormous and pendulous. 
Deep fissures and lymphorrhoea ensue. Occasionally itching, burn- 
ing or pain are present, and genital involvement is accompanied by 
epididymitis, hydrocele, and hernia. There may be reflex nausea 
and vomiting. 

Course. The disease usually follows on inflammation or infec- 
tion which produces lymphatic obstruction; such as filariasis, ery- 
sipelas, cellulitis, lymphadenitis, or the removal of lymph glands. 
Kecurrences of the local inflammations, ofteu accompanied by fever, 
increase the degree of the pathological process, intensifying the ana- 
tomical changes until the picture above described is produced. 

Varieties. The clinical varieties have been indicated in the 
description. They are telangiectatic or naevoid elephantiasis, 
and the lymph scrotum. 

Elephantiasis telangiectoides, telangiectatic lymphangitis, or 
naevoid elephantiasis is congenital and often associated with a naevus 
or hemangioma. The lesions are usually visible, but at times may 
be detected only by palpation, the overlying skin being raised though 
otherwise normal. The lips and cheeks are thus affected with 
perhaps more frequency than any other part of the bodv (Chapter 
XXXII). 

Lymph scrotum is also called nevoid elephantiasis or varix 
lymphaticus. It starts with fever, swelling, redness and vesicula- 
tion of the scrotum. The vesicles burst and lymph wells up. A con- 
stant increase in all the symptoms takes place. 

Differential Diagnosis. The condition is easy to recognize, but 
it is important to determine the underlying cause. (See Etiology.) 

Etiology and Pathogenesis. Eilaria are the cause of most of 
the tropical forms. The other varieties, excepting the congenital 
naevoid type, are due to mechanical obstruction of the lymphatics, 
following neoplasms, scars, pregnancy, ulcers, erysipelas, chronic 
dermatitis, syphilis, tuberculosis, lymphadenectomies, and diseases of 
deeper tissues such as osteomyelitis. These factors, either by pres- 
sure or inflammation, stop the lymph circulation and thus, through 
lymphedema and consequent over-nutrition, provoke hyperplasia and 



HYPEKTKOPHIES OF THE CONNECTIVE TISSUE 201 

hypertrophy of the tissues with such secondary changes as the for- 
mation of warty proliferations, lymphangiomata and the like. 

Treatment. Aside from prophylaxis as regards filariasis. only 
surgery offers any hope in elephantiasis. In mild cases elastic 
bandages are useful. Scars must be excised if it is thought that 
these, by pressure, produce the disease. The local skin modifications 
secondary to elephantiasis must be treated symptomatically accord- 
ing to their nature. This, however, is purely palliative. 

Prognosis. The prognosis is always poor as regards overcoming 
the condition, unless the underlying cause is curable. 

The rarer conditions are numerous, but so unusual as to require but the 
briefest mention. They all exhibit a hyperplasia of the connective tissue, 
or an alteration thereof, a chemical disturbance leading to its volumetric 
increase. Etiologically the conditions are perhaps unrelated. Two, scler- 
ema and edema neonatorum are congenital; one, Milroy's disease, is heredi- 
tary; two, acromegaly and myxedema, are due to a disturbance of the 
endocrinous glands, and one, cutis verticis gyrata, is still unexplained as 
to origin. In addition, dermatolysis must be here included, largely because 
it appears to be either a connective tissue or elastic tissue disease, and 
although it is not actually a hypertrophy, it has some features suggesting 
association with this process. 

-Sclerema Neonatorum, also called Scleroderma Neonatorum, occurs some 
time between birth and the tenth day of life. The lower extremities turn 
white, feel impliable, and the disturbance progresses to the lumbar area 
creeping upwards, and finally, if the child lives long enough, includes the 
entire skin. The integument feels as if it were half frozen, the joints 
are immobile, the mouth can be opened with difficulty, the general temper- 
ature is subnormal and the pulse is slow. Prematurely born and weak in- 
fants present the condition in a primary form, but it arises also second- 
arily as a result of persistent diarrhoea. 1 The treatment consists of main- 
taining the body temperature by applying heat externally, but usually the 
patient dies. 

Edema or Scleredema Neonatorum also arises in premature, feeble babies, 
starting as an edema which pits on pressure and first appears on the lower 
extremities. Eecovery is possible but rare, and the edema progresses, the 
child growing drowsy and finally comatose. Death results from asthenia 
or secondary infection. The condition clinically differs from sclerema 
only in that the skin in the former does not pit on pressure; and patholog- 
ically by virtue of the fact that sclerema exhibits fatty acid crystals and 
scleredema the ordinary minute anatomy of edema. Nearly all of the af- 
flicted die. 

i Probably this is primary also, the diarrhoea and the skin condition both 
being due to the same underlying cause. 



202 DEEMATOLOGY 

Milroy's Disease, or hereditary edema of the legs, is hereditary and 
familial. The legs start to increase in size shortly after birth, and become 
large but not shapeless as in elephantiasis. At times, the involvement 
extends above the knees. None of the characteristics of sclerema or scler- 
edema are present, and the patients usually complete the normal span of life. 

Acromegaly is due to a hypertrophy of or neoplasm in the pituitary body. 
Aside from the well-known evidences of gigantism, the skin and mucous 
membranes show alterations such as hyperpigmentation, scleroderma, hyper- 
hidrosis, hirsutes and hypertrophic scars. The patient is often adipose 
and the nails are sometimes distorted, flattened or grooved. 

Myxedema, also called thyroid cachexia, cachexia strumipriva, or cre- 
tinoid edema, may be acute or chronic and appear either in infancy or 
adult life. The latter form is oftener encountered in females than males 
at or about the time of the menopause. The patient is sluggish, the skin 
translucent, thick, waxy, yellowish and dry, or dry and scaly. Over the 
malars there is usually a flush, the eyelids look puffy, and because of swell- 
ing the nose is thick, the eyes dull, and the cheeks covered by thickened skin. 
The integument elsewhere, particularly over the extremities, wrinkles. 
About the neck there is an increase in fat causing a cushion-like swelling. 
Alopecia develops, surviving hairs being lustreless, dry and brittle. The 
nails furrow, hyperpigmentation appears even to a deep bronzing, the gen- 
eral development is retarded and mentality is of a low order. Thyroid 
insufficiency is the cause. The diagnosis is simple and the treatment con- 
sists of thyroid administration which in many cases produces a cure. In 
some instances thyroid transplantation from sheep has produced a perma- 
nent cure, thus obviating the necessity of constant internal administration 
of the gland substance. 

Cutis Verticis Gyrata is extremely rare. It involves the scalp, so fur- 
rowing the latter that it simulates a convoluted surface. 

Dermatolysis includes two types of disturbances. The first is character- 
ized by masses of pendulous integument almost anywhere on the body, 
some of which suggest fibromata. The second, also known as cutis laxa, 
elastic skin, or hyperplastic skin, is a condition in which the integument, as 
in a puppy or kitten, may be picked up in folds. Upon release, the 
stretched skin springs back into place. 

Paraffin prosthesis is essentially a connective tissue hypertrophy, 
but it may be regarded as a foreign bodied tumor. It arises about 
masses of paraffin injected for cosmetic or legitimate surgical pur- 
poses, but which in susceptible people stimulates connective tissue 
hyperplasia and inflammation. The site injected and immediate 
neighborhood presents the lesion, the size of which is determined by 
the amount of paraffin introduced. A tumor develops which clinically 
may resemble a keloid, fibroma, leukemic infiltrations, sarcoma, or 
sarcoid. It is hard, white, red, purplish or brown in color. It 




Fig. 38. KELOID 

Keloids are spontaneous or secondary, the latter being closely allied to, if not 
identical with hypertrophic scars. Negroes present the lesions more commonly 
than whites. They are pink, red, yellow or flesh-colored, often dendrite, recur when 
excised, and structurally are identical with fibromata. Their commonest site is the 
thorax or near it. 



HYPERTROPHIES OF THE CONNECTIVE TISSUE 203 

feels rough and hard and is immovable in the skin, but moves with 
the skin over the tissues below. Cures cannot easily be effected. 
Small tumors may be excised. This is not possible, however, when 
the involvement is extensive. All other therapeutic measures are 
useless. 



CHAPTER XVII 

ATROPHIES OF THE CONNECTIVE TISSUE 

Atrophies of the skin itself are usually due to a disturbance of the 
collagen leading to its ultimate thinning. Very frequently the elas- 
tic tissue also degenerates. From the clinical standpoint all dis- 
eases should be here included which terminate with thinning of 
the skin, except atrophic scars, and the atrophic stages of the eryth- 
rodermas and dermatitides. In the last mentioned the atrophy is 
not essential, nor frequently enough a part of the picture to justify 
its consideration under the atrophodermas. The commoner forms 
are: 

A. The Scleroderma Group 

1. Scleroderma (Fig. 39) 

2. Morphoea (Guttate) (Fig. 40) 

3. Sclerodactyly 

4. Hemiatrophia facialis 

5. Ainhum 

B. Idiopathic Atrophy Allied with Scleroderma 

1. Diffuse Idiopathic Atrophy 

2. Acrodermatitis Atrophicans 

C. Macular Idiopathic Atrophy or Atrophia Maculosa et Striata 

D. Senile or Regressive Atrophies 

1. Senile Atrophy and Atrophy Due to External Causes 

2. Kraurosis 

3. Striae et Maculae Distensae 

E. Rare Forms 

1. Glossy Skin (possibly related to Scleroderma — A. 1) 

2. Multiple Benign Tumor-like Growths of the Skin (possi- 

bly related to Atrophia Maculosa — C). 

SCLERODERMA (FIG. 39) 

Synonyms. Hide-bound ; Dermatosclerosis ; Scleriasis ; also Adult 
Sclerema; German, Sclerodermic; Hautsclerem; French, Sclero- 
dermic. 

204 



ATROPHIES OF THE CONNECTIVE TISSUE 205 

Definition. Scleroderma is an induration of the skin followed 
by an atrophy. It is a chronic disease beginning insidiously, ex- 
tending gradually, and leading to atrophy so slowly that a pro- 
longed period is consumed in the entire evolution. 

Symptoms. The disease begins with a thickening or even edema 
of the skin. The integument is firm, cannot be pinched or raised, 
and is dusky red or violaceous in color, resembling in consistency a 
mature erysipelas. Pain, burning, itching, parasthesia, neuralgias, 
malaise and even mild fever have been noted at this stage, which 
is known as the first, indurative or edematous period. Beginning 
at a given site it becomes diffuse, including at times the entire body ; 
or, it may even start extensively. It progresses, and the moving 
margin is elevated, hard, and in sharp contrast to the neighboring 
normal areas. As already mentioned it looks like erysipelas, but 
feels waxy rather than brawny, and when edamatous may 
be pitted by pressure. But it differs from erysipelas in that the 
red surface is cool rather than hot. 

After a certain period, if atrophy sets in, and it usually does, the 
skin grows thin, may remain red but often gets white, is cool, glossy, 
tense, and cracks or ulcerates over bony prominences. Often, in 
extreme cases, the entire body is encased in a stiff integument, limit- 
ing or entirely preventing the function of the joints, converting 
the face into a rigid mask, the mouth into an immobile orifice, and 
the hands into talons by retracting the fingers. This extensive type 
is, on the whole, uncommon. Frequently the disease remains limited 
to the legs, or hands, or face. Often the larynx is involved, and the 
voice is pitched to a metallic treble, or a mere whisper. The pa- 
tient feels cold, the skin in places loses its gloss, scales, ulcerates, or 
becomes fissured and dry, and intercurrent metabolic or infectious 
disturbances cause death. 

Course. There are acute or chronic, generalized and symmetrical, 
or asymmetrical localized varieties, determined by the course. The 
first two depend entirely upon the speed with which the disease 
evolves, and the course may be one extending over months or many 
years. The generalized form starts as such, or from a local primary 
area, and the localized types may remain so or become general. Ar- 
rest of the process is possible at any stage, and occasionally complete 
involution takes place. 

Varieties. Besides the varieties determined by course and ex- 
tent, as stated above, there are circumscribed scleroderma (morphoea 
or Addison's keloid) (Fig. 40), hemiatrophia facialis and ainhum. 



206 DEKMATOLOGY 

The last two are rare. Circumscribed scleroderma takes the form 
of islands of disease, which are discrete, raised, circumscribed, and 
shaped as dots, lines or bands. This variety has a prodromal stage 
corresponding to the first period of the general type, followed by an 
atrophic stage. At first the lesions are pink or violaceous macules 
developing slowly or rapidly, and surrounded by a delicate violaceous 
ring. Later the lesions become yellow, buff, or white, the periphery 
remaining violaceous; and finally, atrophy, sometimes cicatricial in 
character, develops. The lesions may be single or numerous, sym- 
metrical or not, flat or rough, ribbon-shaped, irregular, oval, or of 
any other form. Sometimes pigment surrounds the islands. As 
older lesions atrophy often new ones develop, the entire process 
covering many years. 

A type developing on the legs in the atrophic stage is scaly, cov- 
ered by patches of dermatitis, and the parchment-like skin is so 
transparent that the veins, which are often dilated, shine through 
and can be felt to be lying in a groove of hard, connective tissue. 
This form rarely extends above the knees, but is associated with 
acrodermatitis atrophicans of the thighs, and often other patches of 
circumscribed scleroderma are found elsewhere on the body. 

Guttate MorpJioea is possibly a variety of scleroderma, but it also 
may be a variety of sclerotic lichen, lichen albus, or lichen atrophicus. 
Hence, it is wiser not to describe it directly under scleroderma, but 
as a related condition. It is also called white spot disease and its 
most striking feature is its dead snowy or chalky whiteness. The 
lesions are usually seen on the chest, but may occur anywhere, are 
white, punctate, multiple, grouped, finally atrophic, and surrounded 
by a narrow brown, pink, red, or violaceous margin. They may be 
associated either with other lesions of scleroderma, or with lichen. 
Microscopically, too, they conform with either of these diseases. 

Sclerodactylia is probably sclerodermatous, and it affects the 
feet more than the hands. It starts in childhood, and beginning 
with the smaller members, it gradually includes the entire foot or 
hand, legs or forearms, or all four extremities. It looks and acts 
like scleroderma, but at first may be hard to differentiate from Ray- 
naud's disease, acro-asphyxia, perniones, or thrombophlebitis obliter- 
ans, particularly when necrosis or ulcerations develop. It is often 
associated with scleroderma elsewhere. 

Hemiatrophia Facialis is scleroderma of one side of the face, which in- 
volves the deeper tissues. It is rare and usually accompanied by other 
evidences of scleroderma. 



ATKOPHIES OF THE CONNECTIVE TISSUE 207 

Ainhum is a rare disease restricted almost entirely to Ethiopians in their 
native surroundings. It is characterized by a constricting sclerodermatous 
band surrounding the base of the little toe. This acts as a permanent 
tourniquet, causing all the mechanical changes such an appliance would 
produce, and ultimately leading to spontaneous amputation. 

Differential Diagnosis. The various forms of scleroderma are 
so characteristic that confusion with any other condition is almost 
impossible. 

Etiology and Pathogenesis. Metabolic, emotional, nervous, and 
central nervous diseases, trophoneuroses and angioneuroses, have been 
considered the causes of the malady. We do not yet, as a matter 
of fact, understand the etiology. Its relative similarity to myxed- 
ema, the fact that thyroid medication has improved some cases, and 
pituitary extract others, as pointed out by Johnston (in the 1915 
Session of the American Dermatological Association), indicates that 
probably, at least, some phases of the disease depend upon disturb- 
ance of glands of internal secretion. In one case of guttate morphoea 
I saw marked improvement with pituitary extract; in a generalized 
scleroderma none. The latter patient had a tremendous sugar toler- 
ance. He was able to ingest three hundred grammes of pure sugar 
without getting alimentary glycosuria, although he developed a 
hyperglycemia of 0.2 within an hour. Three-quarters of all the 
cases occur in women. An effort has been made to regard syphilis 
as the cause of the illness, because in a certain number of cases the 
Wassermann reaction has been present. In the few cases in which 
I endeavored to confirm this I have failed, but had the Wassermann 
reaction actually been present, I think I should have interpreted the 
phenomenon as a case of scleroderma developing in a syphilitic, just 
as pneumonia or any other disease might have developed. 

Treatment. Both the local treatment which should be sympto- 
matic, and the general treatment with the usual alteratives employed 
have been unsuccessful. Until thyroid and pituitary gland extracts 
were used the disease appeared hopeless, and even with these newer 
remedies the outlook, though, better, is none too good. 

Prognosis. The prognosis as to cure is always bad. Often the 
disease does not progress and if this is the case the patient may live 
to a fair old age. This is even possible with the generalized forms, 
but in these the last years are spent in helplessness. Death is due 
to some intercurrent illness, or marasmus. The prospects in mor- 
phoea are invariably good so far as life is concerned. 

All forms of cutaneous atrophy about to be described are un- 



208 DERMATOLOGY 

common, if not rare, and from the general physician's standpoint, 
unimportant. While the medical student should be familiar with 
the existence of these conditions, and with their commoner features, 
it is easy to exaggerate their significance for they are incurable. 
Failure to recognize them, although a major offence for an expert, 
would hardly be even a lesser crime for the general practitioner, and 
could in no sense be counted against the student. 

Diffuse Idiopathic Atrophy or Atrophia Cutis Diffusa Idiopathica may 
begin anywhere, some say with infiltrations and others without. The orig- 
inal foci are small, but coalesce and advance over the entire trunk, finally 
leaving the skin translucent, thin, and of the consistence of cigarette paper. 
When pinched up the integument very gradually returns to its former 
place, not springing back as normal tissue would. It feels thin and as if 
no paniculus lay below. The vessels shine through and the lax tissue 
tends to be wrinkled or folded. The condition may be associated with one 
of the other forms of primary atrophy. There is no cure, but the patient 
rarely suffers gravely. 

Acrodermatitis Atrophicans Chronica (Fig. 39) ends with the same type 
of atrophy seen in the diffuse variety. It begins with edema, infiltration and 
redness on the back of the hands and feet, the digits escaping. It progresses 
gradually, involving the extremities, and on the thigh reaches to just below 
Poupart's ligament, ascending laterally, however, to the level of the iliac 
crest, where it ceases to advance. Along the ulna and tibia inflamed, 
thickened bands appear resembling scleroderma. This disease is often 
associated with scleroderma of the legs. 

These two conditions are with difficulty separated from sclero- 
derma, since one, the second, often co-exists with scleroderma, and 
since both begin as inflammatory infiltrations which end as atrophies. 
The main difference between the two conditions is that in its final 
stage, the scleroderma of the skin tends to be hard, and the primarily 
atrophic skin soft. 

Atrophia Maculosa et Striata Idiopathica. This malady may appear 
anywhere on the trunk or extremities. It begins as infiltrated, reddish, 
purplish, pale blue, hard or boggy nodules, which ultimately turn dead 
white, leaving atrophies which clinically resemble vaccination scars, and 
anatomically present the appearance of any cutaneous atrophy. At times 
the lesions are striated. The affected skin is wrinkled, thin and inelastic. 
This final state is known as anetoderma, a descriptive word applicable to 
the ultimate condition of all atrophies. On palpating such a lesion it 
feels like a depression, surrounded by a ring of normal paniculus. Thus, 
the examining finger detects a sensation of entering a shallow pit. 

Senile Atrophy, Atrophia Senilis, or Senile Atrophoderma is due to 
elastic fibre degeneration. The skin is dull yellow, wrinkled, dry, impliable, 
and slightly scaling. It contains telangiectases, and is often covered with 
senile or seborrhoeic warts. 




Fig. 39. SCLERODERMA WITH ACRODERMATITIS ATROPHICANS 

The middle phalanges show scleroderma in the hide binding stage when 
the skin is tense, drawn, red or blue. The rest of the hands show the con- 
dition in the atrophic stage in which the skin is thin, puckered, lax and 
lustreless. This is called anetodermia and is seen in the terminal phases 
of the atrophies as a whole. It is also marked on the forearms. 






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ATROPHIES OF THE CONNECTIVE TISSUE 209 

Kraurosis Vulvae is a rare atrophy appearing after the menopause, 
whether natural or induced. At first small, painful, red indurations ap- 
pear about the introitus. Gradually, the tissue becomes thin, tense, glossy, 
and the process involves the neighboring regions. The labia and clitoris 
shrink and the normal contour of the vulva disappears. In the final stage 
all other atrophies are simulated. 

Striae or Maculae Distensae, also called Lineae Albicantes, can best be 
illustrated by the common examples of the white lines developing on the 
abdomen and thighs during pregnancy. Similar lesions arise after any 
sort of abdominal distension, or in emaciation following adiposity. The 
condition is too well-known and of too little importance to merit more 
space. 

Glossy Shin, or Atrophoderma Neurotica, first described by Paget, is a 
disease of the fingers. These become smooth, glossy, pink, or blotchy red, 
as if permanently frost-bitten, and the nails become convex in both diam- 
eters. At times vesicles, bullae and necroses are noted, and neuralgic 
pain is present in some cases upon motion. Trauma, injury, lepra, in 
short anything capable of causing a trophoneurosis, cause this disease, 
which tends to disappear spontaneously, if the underlying cause is curable. 

Multiple Tumor-Lilce Growths of the Skin are small, bluish-white or slate 
colored lesions, the size of a dime. They puff out and are covered with 
fine, dilated vessels. On palpation, they feel like boggy masses with a 
soft base, surrounded by a firm ring of normal tissue. They end in 
atrophy of the skin and there is a strong suspicion that they are identical 
with atrophia maculosa. 



CHAPTEE XVIII 

PIGMENTARY DISEASES 

Disturbances of pigmentation occur in two great groups, in one 
of which an excess of coloring matter is deposited, and in the other 
of which the coloring matter disappears. The former are called 
hyperpigmentations, the latter depigmentations or leucodermata. 
They may be consecutive conditions, that is, following some pre- 
existing disease of which the pigmentary disturbance is an incidental 
sequel ; or, they may be primary, that is, an essential manifestation 
of the condition in which they arise. 

Depigmentation is always due to the absence of pigment cells, 
also called chromatophores or melanoblasts, or of the pigment gran- 
ules in these cells, or of the pigment in the basal layer of the epi- 
dermis. Superpigmentation is due to either of the two following 
conditions, or sometimes to both. The first of these is an excess 
of the number of chromatophores, or of pigment granules in the 
chromatophores or basal layer, or all three. The second of these is 
the hyperpigmentation following hemorrhage into the skin. Such 
pigment is derived directly from hemoglobin. Pigment as formed 
in chromatophores is called melanin, and its derivation is not per- 
fectly known. It is however under the control of the chromaffin 
system. 

Besides color changes dependent upon disturbances of the pigment 
producing mechanism itself, there are some caused by the introduc- 
tion from without of foreign particles, such as tattoo marks, or a 
deposit of gun powder in the skin. Certain animal parasites, notably 
pubic lice, cause bluish discolorations, the maculae ceruleae or 
taches bleuatres. Absorption of metals, chiefly silver and arsenic, 
imparts abnormal tints to the skin, the former giving the well- 
known picture of argvria, the latter producing brown discolorations, 
while lead and bismuth are responsible for a blue line at the edge 
of the gums. In the manufacture of explosives, particularly melan- 
ite, according to Rendu, the skin on the exposed areas turns canary 

yellow. 

210 



PIGMENTAKY DISEASES 211 

Hyperpigmentation 

A. Derived from melanin 

I. Idiopathic 

1. Chloasma 

2. Lentigo or ephelides 

3. Mongolian spots 

4. Eaevi 

II. Congenital predisposition often precipitated by external 

causes 

1. Lentigo or ephelides 

2. Pigmentation in xeroderma pigmentosum 

3. Naevi 

III. Metabolic disturbances and infections 

1. Addison's disease 

2. Cachectic bronzing 

3. Chloasma (uterine and the like) 

4. Graves' disease 

5. Lepra, syphilis, tuberculosis, lichen planus 

IV. Injuries, scars, etc. Radiodermatitis, weather beating, 

sunburn, pigmentation in scars 

B. Derived from Hemoglobin 

I. After purpuras and other hemorrhagic diseases 
II. Scars, particularly fresh scars, following injury, tubercu- 
losis, syphilis, ulcers, etc. 
III. After inflammations as dermatitis, body lice. 
IV. Metabolic. Hemochromatosis, or bronzed diabetes. 

C. Derived from ingested, injected or absorbed drugs or chem- 

icals, arsenic, silver, lead, bismuth 

D. Foreign pigments introduced from without 

I. Tattooing or gun powder spots 
II. Maculae ceruleac (pubic lice) 
III. Blue pigmentation following hypodermatic injections 

For the sake of brevity these relatively unimportant phenomena 
will not be treated in so detailed a manner as the more significant 
dermatoses. 

Chloasma is idiopathic or symptomatic. Idiopathic chloasma is 
secondary pigmentation following any cause at all, and the word is 
synonymous with hyperpigmentation from an excess of melanin. 
Symptomatic chloasma is best illustrated by the uterine variety. 
This occurs as the result of a disturbance of the internal generative 



212 DEKMATOLOGY 

organs, — pregnancy, ovarian disease, pelvic tumors, etc. It con- 
sists of a facial discoloration, yellow to deep brown in color. Such 
changes are physiological and transitory during gestation, when they 
are also present near the nipple and on the abdomen. (Linea nigra.) 

Lentigo or ephelides are freckles. 

Mongolian spots are possibly naevi in the widest meaning of the 
word. They are congenital blue, black, or purplish macules from 
one to ten centimeters large, and lying over the lower sacral regions. 
Usually they leave in the third or fourth year. 

Naevi will be considered in a separate chapter. 

Xeroderma pigmentosum is partly characterized by freckle-like 
hyperpigmentations. (Chapter XXIX.) 

Addison's Disease may cause general or local pigmentation. It 
is seen as brown areas in the body folds, on or about the nipple, 
genitals, face, neck, and buccal mucosa. Any trauma causes hyper- 
pigmentation. The general symptoms of asthenia are present, and 
the disease is generally due to tuberculosis of the suprarenal body. 
As the pigmentation progresses, the entire body becomes mahogany 
colored and the patient dies either of asthenia, or of general 
tuberculosis. 

Bronzing is often present in any condition causing cachexia. This 
type is known as cachectic bronzing, and the underlying cause may 
be malignancy, or a chronic infection, or any other condition leading 
to marasmus. 

Graves' Disease gives rise to freckles in large numbers on those 
areas in which such lesions would normally appear. 

Lepra, syphilis and tuberculosis cause various types of hyperpig- 
mentation. 

The hyperpigmentation excited by X-Rays is determined by the 
extent and length of the exposure. It may take the form of freckles 
or general tanning, just as sunburn would. 

The last condition mentioned is too well known to require detailed 
discussion. 

Pigmentation in scars is derived either from hemoglobin, or is 
melanotic. The former is more frequently present in young, the 
latter in old scars. It is either in or about the cicatrix. 

Purpuras and other hemorrhages in fading leave blood pigmenta- 
tion for a time. 

Lichen planus after fading leaves melanotic macules at the site 
of the vanished papules. 

Some forms of dermatitis, dermatitis herpetiformis, prurigo, 



PIGMENTAKY DISEASES 213 

herpes zoster, and body lice leave pigmented spots, frequently de- 
rived from hemoglobin, often, however, of melanotic origin. 

Hemachromatosis is seen in cirrhosis of the liver and pancreas, 
and when associated with diabetes, the latter disease is characterized 
as diabete bronze. 

Arsenic causes diffuse or freckle-like pigmentation; silver, a dif- 
fuse ivory blue discoloration (argyria) ; lead and bismuth dark 
lines on the gums near the teeth. 

Tattooing is well known by all. 

Gunpowder, when explosions occur near the skin, is driven into 
the latter causing deposits which look like blue-black ink spots, just 
under the cuticle. 

In pediculosis pubis bluish macules (maculae ceruleae) are seen 
chiefly on the abdomen. 

After injections of morphine, particularly in adults, a rare con- 
dition of bluish discoloration of the skin is at times encountered. 

The treatment of these stains is not satisfactory. In the types 
due to metabolic diseases, drugs or chemicals, amelioration of the 
underlying cause, or cessation of the drug, may suffice to cure the 
skin disturbance. All attempts to remove the spots are vain, as 
they recur. Therapy depends upon causing exfoliation of the cut- 
icle. Thus, one to three percent, solutions of bichloride, or twenty- 
five percent, lotions of ammoniated mercury, or a solution such as 
Van Harlingen's may be employed. 

IJ Hydrarg. Chlorid corrosiv 4.0 

Zinci Sulph. 

Plumb Subacetat aa 2.0 

Aq. dest. qs. ad 120.0 

Sig. Apply twice daily. 

Tattooing may be partially removed by causing inflammation 
with thirty parts of zinc chloride in forty of water. This causes 
an eschar to form, and when the latter falls off the decoration is 
gone. There is danger, however, of excessive destruction of tissue. 
Perhaps the safest way of producing good cosmetic results is by 
conservatism and concealment. Liquid powders to be applied as 
needed are the best, as follows : 

^ Zinc oxide 

Mag. ustae aa 15.0 

Glycerin 10.0 

Extr. violet fluid 0.6 

Alcohol qs. ad 150.0 

Sig. Shake well and apply as needed. 



214 DEKMATOLOGY 

This fluid is to be thoroughly shaken and after it has dried upon 
the skin the excess may be removed with a soft, linen cloth. If a 
pink rather than white surface is desired, five parts of powdered 
calamine may be incorporated in the lotion. 

DEPIGMENTATION, OR PIGMENT ATROPHY 

Disappearance of pigment is due to a variety of conditions, but 
the ultimate cause has not yet been explained. The varieties may 
be classified as follows : 

I. Idiopathic 

1. Congenital 

a. Albinism 

b. Naevus anemicus 

2. Acquired vitiligo' 

II. Metabolic and Infectious in Origin 

1. Leucoderma syphiliticum 

2. Leucoderma psoriaticum 

3. White Spot Disease 

a. Morphoea 

b. Lichen albus, sclerosus and morphoeicus 

4. Skin atrophies (other than those included in 3 a-b) 

III. Injuries; Depigmented scars, lineae distensae, leucoderma 

from chrysarobin 

IV. Degenerations; colloid milium and degeneration 

VitiligOj called achromia, piebald skin, and also having other 
less important synonyms, is a white macular eruption with borders 
of hyperpigmentation about the colorless islands. These islands are 
circular, oval, irregular in outline, striated or mixed in type. They 
are clear white, numerous or sparse, flush with the skin and in no 
wise changed from the norm, grossly or microscopically, except that 
they lack pigment. Hairs upon such patches may or may not be 
white. The lesions may coalesce and simulate albinism. They are 
found anywhere on the body, but chiefly on the face, neck, extremi- 
ties, genitals and trunk. In summer, the spots become pink because 
they lack the protection that pigment furnishes against the sun's 
rays. 

The appearance of a patient with vitiligo is characteristic. Snow 
white patches of various size and shape, as described above, fleck the 
skin, and they are surrounded by a zone of apparently deeper pig- 
mentation. At first a few spots appear and gradually more develop. 



PIGMENTARY DISEASES 215 

In summer the tanning of the normal skin emphasizes the contrasts. 
No subjective symptoms are present, but often the patient becoming 
self-conscious grows depressed, or even melancholy. Nothing is 
known of the etiology of the disease and all treatment is in vain. 

Albinism, which may be partial or complete, is due to a congenital 
absence of pigment, often including the choroid. The skin is milky 
or pinkish-white, the hair is almost totally white, the iris is trans- 
parent and may look pink, and recovery is impossible. Because of the 
ocular condition mild photophobia and pupillary instability are pres- 
ent. In some instances heredity plays a causative role. 

Naevus anemicus will be discussed among the naevi. (Chapter XXXII.) 
Leucoderma syphiliticum will be described in connection with syphilis. 
(Chapter XLII.) Leucoderma psoriaticum is rare. At times after the dis- 
appearance of psoriasis there is a permanent absence of pigment. Morphoea 
(Chapter XVII) and Lichen alius, sclerosus or morphoeicus (Chapter 
XIII) have been described. Many of the skin atrophies (Chapter XVII), 
including lupus erythematosus (Chapter XXV), are pure white in the final 



Scars may be depigmented as well as over pigmented. Lineae distensae 
or albicantes, observed on the abdomen and thighs in pregnancy, or in con- 
nection with abdominal tumors, ascites, et cetera, are white lines. These 
are atrophies secondary to elastic tissue rupture* and rarification of the 
collagen, incidental to the unusual strain on the skin in abdominal dis- 
tension. Leucoderma at times follows the use of chrysarobin. Colloid de- 
generation (Chapter XIX) is not a true depigmentation. The conditions 
enumerated in this paragraph are not serious, but are intractable. 



CHAPTER XIX 

DEGENERATION OF AND IN THE CONNECTIVE TISSUE 

Of this group of diseases xanthoma, xanthelasma and xanthoma 
diabeticorum are important, pseudoxanthoma elasticum is of interest. 
while colloid degeneration, calcification and dermatolysis are of 
minor significance. All represent some alteration either in the col- 
lagen or elastic tissue. Xanthelasma, the old xanthoma planum, is 
a muscular degeneration, and dermatolysis is either an elastic tissue 
disturbance, or a myxomatous degeneration. The latter is closely 
related to neurofibroma, if not identical therewith and it is a ques- 
tion whether it is a new growth, or whether neurofibroma, though ap- 
parently a neoplasm, is not actually also a degeneration. Arguments 
favoring either view might be advanced, but in this work neuro- 
fibroma will be included among the benign connective tissue neo- 
plasms, according to classical usage. 

A great deal of confusion has existed in the past regarding the 
relation of xanthelasma, or xanthoma planum to xanthoma tuberosum. 
They are, however, both clinically and anatomically separate con- 
ditions, as will appear below, and it is mainly due to Pollitzer's 
convincing studies that they have been separated. To-day there is 
no justification for any confusion, and the fact that their separation 
has not yet been universally accepted indicates only inertia on the 
part of students and inability or indisposition to admit the obvious. 

XANTHOMA TUBEROSUM (FIG. 41) 

Synonyms. Xanthoma; Xanthoma Multiplex. 

Definition. Xanthoma tuberosum is a disease characterized by 
the formation of patches, clusters or stripes of yellow nodules, occur- 
ring on the extensor surfaces of the large joints. 

Symptoms. At first minute papules with yellow or orange ele- 
ments arise. These increase in size and number forming plaques 
(Fig. 41), striae, nodules, or small sessile or pedunculated tumors. 
The lesions are discrete or coalesced, and as new ones appear among 
the old, great variations in size, shape and color are seen. They 
may be barely visible, or as large as a pecan nut, pink, yellow, or 

216 



DEGENEKATION OF AND IN CONNECTIVE TISSUE 217 

orange, according to the proportion of vascular dilatation or lipo- 
chrome present, and in consistency they are hard or soft according 
to the relative proportion of fibrous connective tissue, or fatty sub- 
stance. At times single lesions may exist. In general the disease 
is not confined to the extensor areas, but spreads, although not densely, 
to other parts of the body, involving exceptionally the cornea, con- 
junctiva, respiratory passages, alimentary tract, serous lining of the 
body cavities, and even the solid viscera, large vessels and some 
tendons. 

Course. The disease usually begins in early adult life, but has 
been found in children, and I recall one case in a child under two 
years of age. As a rule the condition does not shorten life, although 
the lesions grow progressively and steadily more numerous. 

Varieties. There is but one form of the disease. Sometimes 
xanthelasma is seen in patients with xanthoma. The connection is 
purely a matter of coincidence. 

Differential Diagnosis. The histology of the condition is dis- 
tinctive. A fibrous connective tissue mass, including an inflamma- 
tory infiltration, xanthoma cells, lymphocytes and giant cells in which 
droplets of fat are found, compose the picture. A knowledge of 
these facts is of diagnostic importance. The disease must be differ- 
entiated from xanthoma diabeticorum and urticaria pigmentosa (Fig. 
4), also called xanthelasmoidea. It can be distinguished from the 
former by determining the presence of diabetes. From xanthelas- 
moidea it is differentiated by the fact that it occurs prevailingly in 
adults, while urticaria pigmentosa always begins in infancy. Xan- 
thoma lesions are tumor-like or nodular, while xanthelasmoidea is 
always macular and when rubbed becomes urticarial. Finally, xan- 
thoma tuberosum has a distinctive microscopic structure, as noted 
above, while the anatomy of urticaria pigmentosa is equally distinc- 
tive, the lesions consisting entirely of mast cells, none of the charac- 
teristics of xanthoma being present. 

Etiology and Pathogenesis. The etiology is not clear. It is 
a disease slightly favoring females, and a few instances of heredity 
have been noted. It shares with all other dermatoses occasional 
association with common systemic diseases. There is no reason, 
however, to believe that it is caused by them any more than a 
primary epithelioma of the lip would be due to a co-existing gout, 
or cirrhosis of the liver. It is beginning to be understood, though, 
that the malady depends upon disturbed lipoid metabolism. In ef- 
fect the lesions are connective tissue hyperplasias developing about 



218 DEKMATOLOGY 

cholesterol-fatty acid esters extravasated into the cutis, as Pollitzer 
and Wile pointed out. The extravasation is referable to cholester- 
inaemia, and experimental corroboration of this fact has been fur- 
nished by Lebedew, who fed cholesterin to rabbits causing an ali- 
mentary cholesterinaemia, and producing typical lesions of xan- 
thoma tuberosum at sites injured by a seton. These observations 
also elucidate the fact of the greater frequency of the condition in 
women who commonly have cholesterinaemia during pregnancy. 

Treatment. Excision offers the only hope of cure. 

Prognosis. The outlook for a cure is poor, as it is nearly im- 
possible to remove the hundreds of tumors covering the body. Aside 
from its annoyance to the patient, the illness is harmless. 

Xanthelasma (Fig. 42) (Pollitzer) is a disease of the eyelids. 
Other similar lesions on the face and neck are probably flat forms 
of xanthoma tuberosum, although those of the neck may be true 
xanthelasma as will be pointed out below. The lesions are either 
tiny or as large as the lids, neither raised nor depressed to the touch, 
although they often look elevated. They are more frequent on the 
upper lid, near the inner canthus, and may be single or multiple. 
In color, they are chrome, or orange, or tawny. They feel like nor- 
mal skin, are sharply marginated, and if one looks away while pal- 
pitating it is impossible to tell when one crosses the lesion. They 
appear in middle life and their cause is unknown. In no sense are 
they neoplasms, and as Pollitzer has demonstrated (Jour. Cutan. 
Dis., Vol. XXVIII, P. 633) they are due to a fatty degeneration of 
the fibers of the orbicularis palpebrarum. Those on the neck are 
probably due to a similar process in the platysma. The best therapy 
is electrolysis as applied for naevi, and although the lesions never 
disappear spontaneously they are always curable by proper treat- 
ment. There is no connection clinically, etiologically, or anatom- 
ically between xanthelasma and xanthoma tuberosum. Their only 
common feature is their color. If they both exist in one person, it is 
purely coincidence, just as a person with cancer of the stomach may 
have a rodent ulcer on the face. 

Xanthoma diabeticorum is a rare condition associated with diabetes. 
The eruption appears suddenly and, when the cause is appropriately treated, 
vanishes promptly leaving no trace. Clinically, there is an extensive out- 
break of small conical or pointed papules with red bases and yellowish 
apices. The entire body is usually covered, including the visible mucous 
surfaces. 

Pseudoxanthoma elasticum, among the rarest of skin diseases, is usually 





Fig. 41. XANTHOMA TUBEROSUM 

This is a papulonodular disease. The extensor 
surfaces are favored but lesions may occur anywhere, 
and they vary in size as indicated here. There often 
are hundreds of lesions on the body. Over the el- 
bows, plaques may form. The color is canary yel- 
low, yellowish red, orange or even purplish brown, 
and the surface is waxv or glistening. 



Fig. 42. XANTHELASMA 

This condition was formerly called xanthoma planum. The eyelids are affected. In 
color, the lesions are yellow, orange or brown. They feel soft and are due to a fatty 
defeneration of the fibres of the orbicular muscles. 



DEGENERATION OF AND IN CONNECTIVE TISSUE 219 

found upon the trunk, near the axillae, thighs or elbows. It may be seen 
elsewhere, and Kingsbury presented a case at the American Dermatological 
Association in 1915, in which the lesions were present on the neck. The 
lesions are yellow or orange and consist of flat papules, as small as pin- 
heads, or by fusion forming a reticular patch, sometimes four or five inches 
in its long diameter. Its essential microscopic feature is a disturbance of 
the elastic fibers which are fragmented, curled, swollen, and often basophilic, 
the normal fibers taking only acid dyes. 

Colloid degeneration, hyaloma, or colloid milium is rare. The lesions 
are tiny flat elevations, yellowish or white in color, and range from bare 
perceptibility to an eighth of an inch in diameter. They glisten and con- 
tain a jelly-like substance which exudes when the lesion is pricked. They 
are generally found on that portion of the face above the level of the mouth, 
chiefly on the forehead and near the eyes. The lesions may be cured by 
curettage or electrolysis. 

Calcification is extremely rare. Calcareous deposits form in the contents 
of sebaceous glands which have become minute retention cysts. The 
lesions are dry and white. Calcification has also been known to have oc- 
curred in inflammatory areas, notably in tuberculosis. 

Dermatolysis occurs in two forms — a general laxness of the skin, and a 
type resembling Recklinghausen's Disease. Cutis laxa resembles the skin 
in kittens or puppies. It is capable of inordinate stretching and promptly 
snaps back into place. It is due to redundancy of the elastic tissue. The 
type of dermatolysis resembling neurofibromatosis is a myxomatous condi- 
tion characterized by pigmentation and the presence of single or grouped 
papules, or small tumors resembling fibromata. This type was recently 
described by Wise and I question whether it was not actually an instance 
of Recklinghausen's Disease. 



SECTION C. PAKASITIC DISEASES AND INFECTIONS 

Infections of the skin are manifold. The pathogenic agents may 
belong to the animal or vegetable kingdoms. The animal parasites 
may be either protozoa, or members of the higher orders, while 
vegetable parasites are either bacteria or fungi. Properly speaking, 
since syphilis is caused by a protozoon, it belongs among the diseases 
to be described in this section. Because of its importance, however, 
it has seemed wiser to devote a separate and entire section to this 
malady. (Section E.) 



221 



GE0UP 6. INFECTIONS 
CHAPTEK XX 

DISEASES CAUSED BY MULTICELLULAR ANIMAL PARASITES 

Animals of several phyla are pathogenic to the skin. They act 
in a transitory manner as jelly fish, bees, wasps, mosquitoes; or 
cause veritable infections as scabies, grain itch, or pediculosis. In 
order to present concisely the range and character of these patho- 
genic agents, the following somewhat pedantic table is inserted. 



Phylum Class 

Coelenterates Scyphozoa 

Plathelminthes Cestodes 



Example 
Aurelia Aurea (jelly fish) 
Taenia Echinococcus 



Nematelminthes Nematodes 



Arthropoda 



Insecta 



Order Aptera 
Order Hemiptera 



Order Diptera 
Order Lepidoptera 



Oxyuris vermicular is 
Dracunculus medinensis 
Filaria medinensis 
Filaria nocturna 
Trichina spiralis 
Ankylostoma duodenalis 
(Uncinaria americana) 

Cimex lectularius 
Pediculi 

'Pulex irritans 
Culex anopheles 
Gastrophilus equi 
Porthesia chrysorea 



r Apis mellifica 
Order Hymenoptera 1 Vespa 
[Formix 



Numulata 



Arachnida Order Acarida 



223 



Pediculoides ventricosus 
Tyroglyphus longior 
Ixodes (several kinds) 
Acarus ( sarcoptis ) Scabiei 
Demodex follicularum 
Leptus autumnal is 

Hirudo Medicinalis 



224 DERMATOLOGY 

Common Name Lesions 

Jelly Fish Urticarial lesions 

Echinococcus Urticaria ; skin cysts 

Thread Worm Dermatitis of the perineum 

Guinea Worm Dermatitis 

Eilariasis Elephantiasis of leg 

Trichina Edema ; urticaria 

Hookworm Dermatitis feet and ankles 

Bedbug Petichiae, wheals 

Lice Dermatitis, papulo vesicular. Pig- 
mentation 

Eleas Petichiae 

Gnats Wheals 

Mosquitoes Wheals ; stings 

Botfly Larva Migrans. (There is doubt at 

present as to whether this disease is 
caused by the named organism or 
some unidentified one.) 

Brown Tailed Moth Dermatitis venenata 

Bees Wheals, edema, petichiae 

Wasps Large urticarial or edematous swell- 
ings, petichiae 

Ants Small wheals 

Mites Grain Itch 

Mites Copra Itch 

Ticks Dermatitis 

Itch Mite Dermatitis or Itch 

Demodex Causes no lesions — resides in pilo- 

sebaceous follicles 

Leech Bite with hemorrhagic centre 

The common important disease in this group are scabies and 
pediculosis. The common unimportant conditions herein included 
are the lesions of stinging insects. The rarer important diseases are 
larva migrans, the dermatitis of the ankylostoma larva, the urticaria 
of taenia echinococcus, the edema of trichuriasis, and the elephantia- 
sis caused by the nocturnal filaria. The remaining conditions are 
either rare or unimportant, or not encountered in the ordinary rou- 
tine of American life. 

The main lesions caused by animals are catarrhal, urticarial or 
hemorrhagic. Thus, the pictures of dermatitis, hives, or purpura 
are those most frequently encountered. Consecutive lesions, 
scratches, scales, crusts and hyperpigmentation are almost invariably 
present in connection with the exudative and urticarial conditions, 
although hyperpigmentation is confined largely to the diseases caused 
by lice and mites. Some of the organisms attack the skin from 



MULTICELLULAR ANIMAL PARASITES 225 

without, as bees, mosquitoes, ants, jelly fish and leeches. Others 
burrow into and live within the epiderm, as in scabies or larva 
migrans. Still others live partly in the skin, by digging their heads 
into the papillary body, as do ticks which nourish themselves by 
sucking blood. Still others reside within the body, causing incidental 
cutaneous manifestations, as the urticara or edema in echinococcus 
or trichiniasis infection; while, lastly, others dwell on the surface 
of the skin, as pediculi. 

scabies (fig. 43) 

Synonyms. The Itch; Seven Years' Itch. French, La Gale; 
German, Kratze. 

Definitipn. Scabies is a contagious skin disease characterized 
by a dermatitis which itches most intensely at night, and which is 
caused by a member of the spider family, the acarus scabiei, the fe- 
male of which burrows into the epidermis. 

Symptoms. The patient presents himself complaining of an in- 
tensely itching eruption, the pruritus being worse at night, and often 
severe enough to disturb or even prevent sleep. An eruption is 
found involving chiefly the body folds, notably about the genitalia, 
in the axillae, umbilicus, between the nates, near the nipples, between 
the breasts and chest, and above all in the interdigital spaces of the 
hands, on the wrists, and to a lesser extent the rest of the body from 
the clavicles to the knees. Involvement of the face and of the legs 
below the knees is most exceptional save in babies, and palmar in- 
volvement is extremely rare, but found occasionally in women and 



The lesions themselves are numerous. In the first place, marking 
the site of the burrows, are small elevated lines, a millimeter or 
more in length, at one end of which rise tiny vesicles. In cleanly 
individuals these lesions are yellowish or colorless. In ill kept 
people, however, they are gray or black, due to the presence of dirt. 
Scratching causes the formation of crusts, minute hemorrhages, 
papules, even lichenification, and when infection takes place an 
impetigo develops. Rarely one sees suppurative paronychia. This 
occurs more frequently in young children than in adults and in the 
former impetigo of the face may develop, resulting from bacterial 
inoculation by impetiginous scabies lesions, but not from the transfer 
of the itch mite to the face. 

At times in well cared for people the cases are atypical, for only a 
few lesions develop, but these itch intensely at some or all of the 



226 DEKMATOLOGY 

usual sites. The consecutive lesions are usually lacking. On the 
other hand, in uncleanly people, the process may go on for so long 
that the combination of filth, crusting, healing up of scales, the num- 
ber of scratch marks, infections, et cetera, cause an exaggeration of 
the common picture. 

Course. Untreated, the condition never heals. Proper treat- 
ment limits the disease at once. It has been stated that an inter- 
current fever, such as typhoid, cures the outbreak. It would seem 
much more likely that the care of the very sick patient, the bathing 
and the like, cure the skin disease rather than that it is cured by the 
influence of the fever. 

Varieties. A severe form, known as Norwegian scabies, was 
first recognized in Scandinavian lands. It is simply' an exaggerated 
variety of the disease in people of subnormal sensibility. Thus, in 
anesthetic lepers, and perhaps in patients suffering with syringo- 
myelia, the condition may be encountered. 

Differential Diagnosis. The nocturnal itching and typical local- 
ization, the demonstration of the mites secured from the burrows, 
are diagnostic features of the disease. Dermatitis hiemalis, pru- 
rigo (Fig. 5) and vesicular dermatitis (Fig. 11) resemble scabies. 
The history of seasonable eruptions in the first of these, the per- 
sistence of the second, the fact that the third itches as much by day 
as by night, the absence of the acari, and the circumstance that in 
scabies usually several members of the family are ill, constitute the 
essential features to be considered. 

Etiology and Pathogenesis. The cause of the disease is the 
acarus scabiei. The female after impregnation burrows into the 
epiderm, depositing one or two eggs a day. In from ten to twenty 
days she dies, but the young are hatched out in about ten days and 
escape to the surface of the skin where, after a brief metamorphosis, 
impregnation occurs, the females burrowing, the males dying. Be- 
sides the human variety of acari, there are others infecting various 
wild and domestic animals, both birds and mammals. These are 
pathogenic to man also. The disease provokes an eosinophilia. 

Treatment. There are many methods of treatment, but only one 
which need be remembered, and for this but three substances need 
be employed, — sulphur, balsam of Peru and styrax. Any one of 
these drugs is used in ten percent, strength in some ointment base. 
Cold cream is the pleasantest. An ounce of this salve is rubbed in 
vigorously on four successive nights over the entire body from the 
clavicles to the shins, with special reference to the various body folds 



MULTICELLULAR ANIMAL PARASITES 227 

and interdigital spaces. A long, hot, soap bath precedes the first and 
fourth inunctions. Exactly ten days after commencing the first 
course of treatment, a second identical course is begun and carried 
out punctiliously, whether the patient seems well or not. The pur- 
pose of this is to forestall a recurrence which may be started by a 
few surviving ova in the burrows. The balsam of Peru ointment is 
preferable, as the sulphur often causes dermatitis. Should der- 
matitis appear, it must be treated as outlined in the chapter on this 
disease. Usually, marked relief is noted after the first inunction, 
and complete relief after the third. At times, more than two 
courses of rubbings are required. Since a few of the acari may have 
found their way into the patient's bed, it is wise to dust sulphur 
powder on the mattresses, and to use fresh sheets when the first 
course of treatment is finished. 

Prognosis. This is always good. It is rare to encounter a case 
which cannot be cured with three courses of rubbings with balsam of 
Peru salve, and it is indeed most exceptional that more than two 
such courses should be needed. 

PEDICULOSIS 

Synonyms. Phthiriasis ; Lousiness ; French, Phtiriase ; La Pedi- 
culosis. German, Pediculose; Lausesucht. 

Definition, Pediculosis is a common disease caused by the hemip- 
terous insects called pediculi or lice. These insects are of three 
well-known varieties, afflicting the scalp, pubis and body. 

Symptoms. Constant itching, certain inflammatory and infec- 
tious manifestations, and the presence of lice and their ova charac- 
terize the clinical picture which varies, however, according to the 
type and site of the infection. These features in turn are determined 
by the variety of the louse. 

Course. Unless properly treated, the disease would go on forever. 

Varieties. These, with the detailed symptomatology, diagnosis 
and treatment, will be considered as independent diseases. 

PEDICULOSIS CAPITIS 

Synonyms. Head Lousiness. 

Symptoms. The scalp and beard are affected. Aside from the 
presence of the lice and ova, the skin may exhibit dermatitis, im- 
petigo or both, and scratch marks, crusts, scales, seborrhoea and a 
nauseating odor participate in the symptom complex. The occipital 
and post auricular areas are most densely involved, the lice scurrying 



228 DEKMATOLOGY 

in and out among the hairs. To the shafts of the hair, particularly 
behind the ears, are attached the ova. They are white or yellowish 
and project from the hair, as do the tufts from the stem of the 
pussy willow. They can be removed only with great effort, because 
they are glued on with a stout cement. The post cervical glands, 
particularly in children and weak people, are enlarged and often 
suppurate causing systemic symptoms. Often a mild dermatitis of 
the face, neck and shoulders develops, and even conjunctivitis, al- 
though the head louse never actually affects the lashes. Itching is 
severe and scratching constant. Thus, impetigo (Fig. 56) of the 
face may arise. In extreme cases the hair becomes matted with 
crusts and serum forming an inextricable tangle, the so-called plica 
polonica or Weichselzopf of the Germans. 

Diagnosis. In the cleanly this may be difficult, but a careful 
search for nits should be made, however unlikely it seems that a 
given individual may have the disease. A mild persistent dermatitis 
of the face, the presence of enlarged cervical or post auricular glands, 
are very suspicious. In children, most cases of facial impetigo are 
due to lice or nits. At times in adults the former may be sparse and 
the latter numerous. 

Etiology and Pathogenesis. The immediate cause of the dis- 
ease is the head louse or pediculus capitis. The mode of transmis- 
sion is by contact with infected people or objects. Children in 
school, and children and women working in shops and factories are of- 
ten infected by companions. At times nurses transmit the disease to 
their charges. Sleeping in public beds, as in hotels, sleeping cars 
and on vessels are mediate causes of the disease. A common mode 
of transmission is by the indiscriminate use of combs and brushes, 
and by the trying on of hats at milliners', even those located in ultra- 
fashionable shopping districts. 

Treatment. It is unnecessary to use the traditional petroleum 
or delphineum. A ten percent, solution of balsam of Peru in alco- 
hol will kill the lice. It should be applied thickly and after twenty- 
four hours a shampoo is necessary. All of the living organisms and 
the contents of the majority of the ova will be destroyed. Should a 
dermatitis or impetigo of the scalp or face be present, a five to ten 
percent, ammoniated mercury cream applied once daily will effect a 
cure. The best way to remove the nits in little boys is to cut off the 
hair. In girl babies this is also feasible. In older girls and adults 
the hair should be washed off with equal parts of vinegar and hot 
water, and while still wet should be fine combed. It is wise to con- 



MULTICELLULAR ANIMAL PARASITES 229 

tinue this once a week for three months, as occasionally a viable ovum 
may be overlooked. 

PEDICULOSIS CORPORIS (FIG. 44) 

Synonyms. Pediculosis vestimenti; Body Lice; Phthiriasis. 

Definition. Pediculosis corpis is a polymorphous irritative dis- 
ease caused by lice which inhabit the seams of underclothes and 
travel thence, temporarily to thrive upon the host whose blood they 
suck. 

Symptoms. The lice suck the blood from the follicles. They 
provoke itching and thus the host scratches, leaving characteristic 
excoriations, linear, parallel (Fig. 44), crusted, and usually found 
where the clothes press against the skin. Hence, the regions most 
affected are the scapular areas and the waist. Here in great num- 
ber, and elsewhere in smaller number are seen the above mentioned 
excoriations. Papulo-vesicular dermatitis which is often crusted, 
pigmented and impetiginous completes the picture. The pigmenta- 
tion at times is as deep as that of Addison's Disease. In neglected 
cases the skin becomes dark and lichenined, constituting the so-called 
vagabond's disease. Secondary infections and glandular enlarge- 
ments are frequently seen. Obviously, the patients complain of in- 
tense itching and when undressed constantly scratch. The ova are 
deposited in the fibres of the clothing. 

Course. The disease lasts as long as the cause remains. 

Differential Diagnosis. Prurigo (Fig. 5) and chronic vesicular 
dermatitis are simulated, but the class of patients usually affected 
and the characteristic excoriations usually indicate the real nature 
of the disease. The lice are found in the seams of the underclothes, 
particularly woolen ones. The nits are attached to the filaments of 
the material. 

Etiology and Pathogenesis. The immediate cause is the pedi- 
culus vestimenti or corporis. Filth and crowded surroundings favor 
infection. This organism is the one now famous in military lore 
as the " cootie." In the past few years its nature and significance 
have become better understood than formerly. This is due to the 
fact that it transmits the organisms of typhus and trench fever. The 
body louse can survive neither in very high nor in very low tempera- 
ture. Thus when patients develop a febrile disease, the lice desert 
the host. In very cold weather their activity is diminished, par- 
ticularly as to reproduction. 

At times the body louse can infest the scalp, and it is supposed by 



230 DERMATOLOGY 

some writers that the body and head louse are identical. This is 
probably not true as the typical body louse is larger and darker in 
color than is the variety infecting the scalp. 

Treatment. The underclothes should be boiled and the outer gar- 
ments subjected to dry heat. A ten percent, balsam of Peru oint- 
ment should be applied to the skin for three or four nights. 

The management of large numbers of infested people, a problem 
recently developed in our armies, has taxed the ingenuity of sanitary 
experts. It is simple enough to rid the the body of lice, but the task 
of delousing clothes is rather puzzling, for dry heat does not pene- 
trate and moist heat shrinks the cheap fabrics with which the world 
was flooded during the war. Major Harry Plotz devised an elab- 
orate delousing plant which in all respects met requirements, save 
that the soldiers complained that the moist heat wrinkled their uni- 
forms. 

Prognosis. This is always good. 

PEDICULOSIS PUBIS 

Synonyms. Crabs ; French, Morpion. 

Definition. This is a parasitic disease caused by the pubic louse 
which attacks all of the body hair and eyelashes, but which usually 
remains restricted to the pubic region. 

Symptoms. Severe itching and the presence of the lice and ova 
constitute the picture of the disease. The organisms and nits are 
found in the pubic, axillary and other body hairs and eyelashes. 
The nits cling to the hairs as do those of head lice. Evidence of 
inflammation and pruritus are present. 

Course. The disease ends only with the removal of the cause. 

Varieties. Phthiriasis palpebrarum, due to the presence of the 
lice in the eyelashes, causes blepharitis, the pediculi burying their 
heads in the follicles. 

Maculae ceruleae, or taches bleuatres, are slate gray or inky 
macules of a diameter not exceeding one and one-half centimeters. 
They are found on the chest, thighs, belly and arms, chiefly in 
blonds, and are pathognomonic of pediculosis pubis. 

Differential Diagnosis. The presence of the lice, ova and blue 
spots differentiate the disease from ordinary dermatitis. 

Etiology and Pathogenesis. The immediate cause is the pubic 
louse (Pig. 45) which is usually transmitted through intimacy, al- 
though the malady can be acquired by contact with infected bedding 
or clothing. 



MULTICELLULAR ANIMAL PARASITES 231 

Treatment. Mercurial salves and particularly gray ointment, 
and shaving off the affected hairs are to be urgently condemned. 
The former causes dermatitis, the latter more irritation than the dis- 
ease. Balsam of Peru as employed in other types of pediculosis will 
effect a cure within four days. A one percent, yellow oxide of mer- 
cury cream is to be employed for eyelash involvement. 

Prognosis. The prognosis is good. 

STINGS 

Flies, mosquitoes, ants, gnats, black flies, bees, wasps, bed bugs and 
fleas all cause well known lesions. The less severe ones need no 
treatment. Others, particularly those of bees and wasps, will re- 
spond to wet dressings. At times the lesions become infected where- 
upon the treatment must be adapted to the secondary condition. 
Bed bug and flea bites are characterized by central hemorrhagic 
points resembling petichiae. The eruptions of purpura hemorrhagica 
and petichial sepsis are simulated, but the perfect health of the 
patient excludes these conditions. 

Larva Migrans. Synonyms. Creeping Eruption; Dermamyiasis Line- 
aris, Migrans Aestrosa. This rare illness is characterized by the pro- 
gressive extension of a linear lesion, somewhat raised and wheal-like. It 
advances as much as an inch in twenty-four hours. The moving point is 
bright red and urticarial. The older portion of the track is pink. 
Straight, curved and tortuous elements are present, and often the burrow 
doubles on itself. The organism has rarely been seen, but Knowles suc- 
ceeded in demonstrating it in its burrow. Its nature is still undetermined. 
Although there is no substantiation of the fact that it is the larva of the 
bot fly of the genus gastrophilus, this view has not been entirely abandoned. 
Slight itching characterizes the lesions of which as many as thirty have 
been present at once. Treatment is difficult. Even excision of the entire 
burrow often fails. Sand papering the advancing area and rubbing in 
antiseptic ointments, as suggested by Whitehouse, appears to possess some 
value. Among our soldiers, after the recent Mexican campaign, several 
cases developed. 

Ground Itch. Synonyms. Uncinarial Dermatitis. Uncinarial derma- 
titis is caused by the larva of the ankylostoma duodenale. It occurs pre- 
vailingly on the feet, and begins as an itching dermatitis with vesicles, 
bullae and papules which become secondarily infected. These lesions are 
the portals of infection of the hook-worm. The larvae travel from the 
affected sites to the duodenum., there to lodge and produce the symptoms 
of ankylostomiasis. The local condition is best treated by mild antiseptic 
fomentations and salves. The general condition requires the use of male 
fern, eucalyptol or beta naphthol internally. 

Echinococcus. Echinococcus cysts rarely occur in the skin. They may 
suppurate or calcify and give the signs of any other cystic tumor. Kup- 



232 DERMATOLOGY 

tured visceral cysts produce urticaria. This condition also sometimes fol- 
lows aspiration. 

In this connection it may also be mentioned that cysticerci of the taenia 
solium may develop in the skin. They feel like any other nodular lesion 
and are recognizable only under the microscope by finding the scolex in 
the cyst contents. 

Trichina causes edema of the skin, particularly near the eyes. Hyper- 
hydrosis, tingling, pruritus and urticaria are also present. The myalgia 
and eosinophilia are corroborative factors in reaching a diagnosis. 

Filaria sanguinis hominis is introduced by the culex fatigans. Ele- 
phantiasis develops due to a choking up of the lymphatics with enormous 
numbers of worms. Another variety of filaria, the filaria medinensis, dran- 
cunculus or Guinea or medina worm, causes papular, nodular, furuncular 
or ulcerative lesions. These lesions appear near the ankle or foot and more 
rarely on other parts of the body. They develop where the mature worm 
endeavors to emerge. Near the lesion, extending radially thence, may be 
felt the body of the worm under the skin. It feels like a soft, raised, 
elongated mass, three or four inches long by one-eighth inch broad. Before 
rupturing the lesions are tense. In endeavoring to withdraw the worm, it 
sometimes breaks and lymphangitis, or even sepsis develops. 

Oxyuris vermicularis, or thread worm, inhabits the lower bowel. At 
times parasites looking like threads escape to the perineum setting up a 
local inflammation or dermatitis. Weak bichloride enemas, one to ten 
thousand, cure the internal condition and ammoniated mercury ointment 
the external. 

The Aurelia Aurea or common jelly fish of our Atlantic shores causes 
urticarial lesions. 

Pediculoides ventricosus causes grain itch, or acarodermatitis urticar- 
ioides. This disease was studied by Schamherg and Goldberger in an epi- 
demic in Philadelphia. The lesions caused are urticarial, papular and 
vesicular and there are consecutive lesions due to scratching, for the pruri- 
tus is intense. The arachnida inhabit the straw in cheap mattresses. 

Ixodes or ticks are numerous in their varieties. They insert their 
beaks into the skin and suck blood. They may best be removed by drop- 
ping a little turpentine or benzine on the exposed part of the parasite. 
This causes the head to be withdrawn. 

Copra Itch produced by the tyroglyphus longior causes a dermatitis 
resembling grain itch. Demodex folliculorum is a harmless mite inhabit- 
ing the sebaceous follicles, chiefly near the nose. Leeches attack human 
beings bathing in fresh water. They are also rarely employed in medicine. 
The bite is purple, about the size of a dime, and has a red centre at the 
site of the puncture. 




Fig. 43. SCABIES 

Note the wide distribution of vesicular papules from the level of the clavi- 
cles down. Also observe the grouping near the axillae and in the inter- 
digital spaces. This patient being a child, the relation of the lesions to 
the breasts is not shown. 




PEDICULOSIS CORPORIS 



In this form of pediculosis the lice inhabit the under- 
clothes, but irritate the skin as they move about. Thus 
the patient scratches, and the characteristic feature of the 
disease is the shape and location of the scratch marks, 
which are most profuse where the underclothes press 
against the skin. Thus the shoulders and waist are more 
densely covered with excoriations than other sites. The 
scratches are linear and often parallel, as is shown near 
the right shoulder and left flank. 




PEDICULUS PUBIS 



As this parasite causes no typical le- 
sions, but merely a simple dermatitis 
near the affected hairs, the organism 
itself is shown, as the diagnosis some- 
times depends upon recognition of its 
appearance. The pubic, axillary and 
body hairs in general are involved. At 
times the evelashes are affected. 



CHAPTEE XXI 

INFECTIONS CAUSED BY PROTOZOA 

Two conditions are caused by the Leishmania, oriental sore and 
uta; three by spirochaetes, frambesia, syphilis and ulcerating gran- 
uloma of the pudenda ; one by trypanosoma, trypanosomiasis ; one by 
an unknown probably protozoon organism, verruca peruana ; while rat- 
bite fever is possibly due to a spirochaete and possibly a streptothrix. 
Should the latter prove to be correct, rat-bite fever will have to be 
included among diseases caused by vegetable parasites. In the mean- 
time, because the disease is cured by salvarsan, it will have to be 
regarded as of animal origin. Because of the extent and importance 
of the subject, syphilis will be discussed in separate chapters at 
the end of the book. 

ORIENTAL BOH, 

Synonyms. Oriental Sore ; Aleppo, Delhi or Biskra Boil ; Biskra, 
Oriental, Gafsa Button, etc. French, Bouton de Biskra; Bouton 
d'Orient; Chancre de Sahara. German, Endemische Beulen- 
krankheit. 

Definition. Oriental boil is an infectious granuloma of the ex- 
posed areas, chiefly the face, which runs a definite course and ter- 
minates spontaneously in a scar. 

Symptoms. At first a maculo papule arises, which is hard and 
situated on an inflamed base. This scales and secretes a serous 
fluid which dries into an adherent crust covering an ulcer. The 
ulcer grows peripherally, and new lesions running a similar course 
appear near by. By confluence an irregularly outlined ulceration 
develops, the total diameter of which may be three inches. Within 
any period up to a year the lesion scars, leaving a pigmented, de- 
pressed cicatrix. 

Course. The disease has a developmental and involuting stage 
as described above. Spontaneous recovery takes place within from 
a few months to a trifle over a year. 

Varieties. A verrucous form has been described. 

Differential Diagnosis. In countries in which the disease is 

233 



234 DERMATOLOGY 

endemic, the diagnosis is easy. The facts that it affects only ex- 
posed areas, that there are no other evidences of syphilis, and because 
the Wassermann test is negative, rule out the diagnosis of lues. 

Etiology and Pathogenesis. The disease is caused by the Leish- 
niania furuncolosa (Firth) which may be demonstrated in sections 
by the Nocht-Ronianowsky stain. 

Treatment. There is no satisfactory treatment, nor is any nec- 
essary, since the disease always heals of itself. 

Prognosis. The prognosis is good. 

Uta is a Peruvian disease clinically resembling lupus vulgaris, 
and caused by a species of Leishmania. 

FRAMBESIA 

Synonyms. Yaws; Pian. 

Definition. Frambesia is a contagious disease seen chiefly among 
the natives in Northern Africa, Madagascar, Mosambique, Australia, 
the West Indies and Asia. It is caused by a spirochaete and pro- 
duces raspberry-like granulomata. 

Symptoms. There are three periods; that of incubation, a 
primary and an eruptive stage followed, as is believed by some, by 
a later stage corresponding to the tertiary epoch of syphilis. The 
incubation period lasts from a fortnight to a month, during which 
there are mild febrile symptoms, headache, general pains and malaise. 
Thereupon appears the primary lesion which is always extragenital. 
This lesion is a crusted, weeping papule usually surrounded by 
others of a similar character. These unite, forming an ulcer with 
jagged edges. The primary lesion is soft and found on the exposed 
parts of the body. Since native clothing is sparse the exposed 
surface is extensive, so that only the trunk and genitals escape. The 
primary sore either terminates in a scar, or assumes the character 
of the secondary lesions which appear after about three months and 
are immediately preceded by constitutional manifestations similar 
to those of the onset. 

The secondary lesions are irregularly disseminated, red papules 
with crusts. After existing for several weeks they fade leaving finely 
scaling areas; or they develop into raspberry-like granulomata vary- 
ing from one-half to three centimeters in diameter. They exude a 
thin fluid which dries. Such lesions favor the face and extremities, 
and commonly form coalescent rings, chiefly at the mouth and anus. 
Later these lesions grow warty. The palms and soles may be 



INFECTIONS CAUSED BY PROTOZOA 235 

involved by lesions in all of the stages mentioned, or hard papules 
form containing corneous plugs. Itching is occasionally seen and 
within a year the lesions involute spontaneously, pigmented patches 
remaining. Ulcers, too, may form during the eruptive period, and 
later in the disease gummata arise. The mucosa is rarely involved, 
and there are slight adenopathies chiefly in the neck and groin. 

Differential Diagnosis. The course of the disease and dis- 
tribution of the lesions vary slightly from syphilis with which 
it may easily be confused. The Wassermann reaction is positive, 
but the mucous membrane is not involved. It has been believed 
that yaws is a form of syphilis. Frambesia itches and the rasp- 
berry lesions are absent in syphilis, nor does frambesia immunize 
against subsequent attacks of syphilis, which perhaps today is not 
a point of great weight in so far as there are authenic cases of syph- 
ilitic re-infection. 

Etiology and Pathogenesis. The disease is caused by the 
spirochaete pertenuis (Castellani). 

Treatment. Arsphenamin affects yaws as it does syphilis. Mer- 
cury and potassium iodide are also indicated. 

Prognosis. This is invariably good. 

Ulcerating Granuloma of the Pudenda. This disease is rare in our 
climate. It is characterized by an invasion of the genitals and their vicin- 
ity with a cicatrizing ulcer. Extension is peripheral while the centre scars 
over. The scar is nodular and the margin tortuous, elevated, pink or red, 
and shiny. At times other parts of the body than those mentioned may be 
involved, and the lesions may be verrucous, crusted or vegetating. The 
cause is unknown, a bacillus, coccus and spirochaete having been found 
by various observers. Women are more frequently affected and the disease 
always comes after puberty. There are no glandular swellings, and all 
treatment save excision is unsatisfactory. 

Trypanosomiasis is capable of causing varied cutaneous manifestations. 
The disease is due to infection by the trypanosoma gambiense (Dutton) 
transmitted by the tse-tse fly (glossina palpalis) of the Congo. Patients 
afflicted with the sleeping sickness have several varieties of skin lesions. 
The sting of the fly resembles that of a bee or wasp. It is red or blue, 
tender and on an exposed surface of the body. During the course of the 
disease itself, toxic, urticarial and vesiculo-papular eruptions appear. 

VERRUGA PERUVIANA 

Synonyms. Peruvian Wart ; Carrion's Disease. 

Definition. Verruga peruviana is a cutaneous infection, the ac- 
tual cause of which has not yet been demonstrated. It is very 
likely to be a protozoon. This disease is commonly associated with 



236 DEKMATOLOGY 

Oroya fever caused by an unidentified organism, the Bartonia bacilli- 
formis, of a new genus and species. Verruga peruviana occurs on 
the extensor surfaces of the extremities and on the face and neck, 
but rarely on the mucosa. It somewhat resembles frambesia. The 
lesions at first are pink or red and slightly raised, rapidly becoming 
papular or nodular. In this stage they are conical or hemispherical 
and about a centimeter broad. Later they grow warty, red and 
have either a broad or constricted base. At times they are hemor- 
rhagic. Subcutaneous lesions also develop which later ulcerate and 
crust, giving off a fetid discharge from a gray or black floor. 

When associated with acute Oroya fever, a severe intermittent or 
remittent fever, prostration and pernicious anemia develop. This 
condition lasts up to four weeks or so and usually ends in death, a 
few cases, however, recovering. It is after the gradual abatement 
of Oroya fever that the verrucae appear. Chronic Oroya fever runs 
a protracted, mild, febrile course, usually ending in recovery and 
associated with verruca. 

Course. Verruga peruviana appears after acute Oroya fever 
which is not fatal, or in the course of chronic Oroya fever. The 
cutaneous lesions disappear spontaneously as a rule. 

Varieties. There are none. 

Differential Diagnosis. Yaws and syphilis are to be excluded. 
The lesions of yaws contain the spirochaete pertenuis, and many of 
those of syphilis the spirochaete pallida. Neither is associated with 
Oroya fever and in both the Wassermann reaction is present, which 
is not the case in verruga peruviana ; nor is the last disease influenced 
by arsphenamin. 

Etiology and Pathogenesis. Verruga peruviana has been 
known for at least four centuries on the western slopes of the 
Peruvian Andes, but never below an elevation of one thousand feet. 
Occasionally cases, as that reported by Jadassohn and Coles, reach 
Europe and North America. The cause is unknown and, as Strong 
and his associates point out, has nothing whatever to do with that 
of Oroya fever. This has been experimentally proven by inoculat- 
ing a sound person with skin lesions of verruga peruviana. After 
sixteen days typical lesions developed, but no sign of Oroya fever. 
The cause of the latter is a hematozoon attacking the red blood 
corpuscles. It is an independently motile organism occurring in 
rod shaped and rounded forms, and has been named after its dis- 
coverer, Barton. 

Treatment. This is symptomatic. 



INFECTIONS CAUSED BY PROTOZOA 237 

Prognosis. From ten to forty percent, of those affected with 
Oroya fever die. The prognosis of verruga peruviana is good. 

RAT-BITE FEVER 

Definition. Kat-bite fever is a remittent or intermittent febrile 
disease accompanied by skin manifestations. The pathogenic agent 
is introduced by the bite of the black or brown rat. 

Symptoms. At the point of the bite a swelling develops which 
is indurated and bluish or red. Lymphangitis radiates from the 
injury and the regional glands are swollen. The exanthem which 
then develops is bluish red, consists of macules which vary in size 
from two to ten centimeters, or even more. It is generalized and at 
times vesicular or pustular lesions are interspersed among the others. 
Karely the rash is purpuric and at times urticarial. As the fever 
diminishes the exanthem fades, but the latter recurs with each re- 
crudescence. The cutaneous manifestations thus resemble those of 
erythema multiforme. According to Tileston, bluish-red circular 
spots develop. These are one to three centimeters broad, sharp, a 
trifle elevated, and they occur on the cheeks, arm, neck, back, chest, 
belly and thighs. The centre is dark red, five millimeters in diame- 
ter, and the lesions fade and re-appear precisely at the same sites 
with each recrudescence. This form simulates erythema perstans. 

With the rash there is fever (103°-105°), malaise, chills and a 
small, rapid pulse. The patient is prostrated and as the fever drops 
a profuse perspiration arises. The tongue is coated and white. 
Nausea, constipation or diarrhoea, salivation and dysphagia, sug- 
gesting rabies, are present. At times, too, there are splenic and 
hepatic enlargement, myocarditis, and nephritis. The tendon 
reflexes are increased, and occasionally neuralgia, hemiplegia, stupor 
and coma have been noted. 

Course. The disease begins with the rodent's bite. After an 
incubation period averaging twelve days (the extremes being one to 
thirty-five days) the first paroxysm develops. This is a febrile at- 
tack as described above, accompanied by a rash. The paroxysm ends 
within four to five days, and a free interval of similar length ensues, 
followed by another paroxysm. In this manner the disease may 
progress with from one to twenty-six recrudescences, the average 
being three to ten. The entire course usually lasts two months, 
but may be much shorter or prolonged even for two and a half 
years. 

Varieties. There are febrile, sustained febrile and intermittent 



238 DEKMATOLOGY 

types, or a mixed type without any incubation period and with, 
sloughing gangrenous wounds. 1 

Differential Diagnosis. The history of an attack by a rat, 
the character of the fever, and the nature of the rash are dis- 
tinctive. 

Etiology and Pathogenesis. According to Tileston an organism 
resembling that of relapsing fever was found in the blood. 
Scliottmuller described a streptothrix. Tileston cured his case with 
arsphenamin, a fact which indicates the probable protozoon origin of 
the disease. This view had been previously expressed by Crohn 
from whose work the following is quoted : " In favor of a 
spirochaete as the causative agent is the similarity of the disease to 
relapsing fever and syphilis, as regards both the marked nerve symp- 
toms and the apparent curability by salvarsan. In favor of a proto- 
zoon cause is the alternation of the paroxysms with afebrile periods, 
recalling the effects of the malarial plasmodia, though this occurs also 
in spirochaetal diseases." 

Treatment. Arsphenamin should be employed, two or three in- 
jections usually sufficing. 

Prognosis. Ten percent, of the cases die. 

i These facts have been assembled from. Burrill Crohn's excellent paper entitled, 
"Rat Bite Fever"; Arch. Int. Med., 1915, XV., P. 1014. 



CHAPTEE XXII 

INFECTIONS CAUSED BY FUNGI 

Fungi determine a wide variety of cutaneous reactions. Some 
live upon the surface of the skin causing almost no morbid changes, 
their presence alone producing manifestations. An example of this 
is tinea versicolor. Others reside in the supracutaneous hair, as 
trichomycosis. Still others flourish in the hair and follicles, as 
microspora and trichophytons. Of these, some produce scaling, 
vesiculation and pustulation on the scalp or glabrous areas. Some of 
them cause purulent granulomata, as do also actinomycetes, blasto- 
mycetes, and sporotricha. Some, in addition, provoke systemic infec- 
tions. The majority are easily cured by suitable local therapy. 
Others, however, require general medication, — notably actinomy- 
cosis, sporotrichosis, and blastomycosis. Perhaps the best way to 
classify these diseases is parasitologically, as follows: 

I. Saprophytes 

1. Cutaneous 

a. Pityriasis versicolor 

b. Erythrasma 

2. Of the Hair 

a. Trichomycosis 

b. Piedra 

II. Epidermophytia (Figs. 51 and 52) 
III. Dermatomycosis 

1. Microsporosis (Fig. 46) 

2. Trichophytosis (Figs. 47, 48, 49, 50, and 53) 

3. Favus (Fig. 54) 
IV. Blastomycosis (Fig. 55) 

1. Saccharomycosis 

2. Gilchrist's form 
V. Eay Fungi 

1. Actinomycosis 

2. Madura foot 

VI. Sporotrichosis 

239 



240 DERMATOLOGY 

SAPROPHYTIC DISEASES 

Saprophytic skin diseases are caused by the presence upon the 
skin of fungi incapable of producing profound pathological changes. 
The micro-organisms flourish in superficial cuticular levels, or on 
the hairs. The diseases in question are pityriasis versicolor, 
erythrasma, trichomycosis palmellina, and piedra. 

PITYRIASIS VERSICOLOR 

Synonyms. Tinea Versicolor; Chromophytosis ; German, Klein- 
flechte. 

Definition. This is a mild, scaling, brownish eruption seen on 
the trunk, and rarely on the thighs and arms as well. 

Symptoms. Usually the front of the chest is covered by fawn- 
colored spots of various sizes. On close inspection the smallest of 
these macules are seen to correspond to the periphery and imme- 
diately adjacent area of the follicles. The larger ones are formed 
by coalescence of the smaller into irregularly circular, oval, or finely 
jagged macules. A very fine furfuraceous scaling is present. At 
times, the macules themselves run together into large sheets beyond 
the border of which smaller lesions arise, with areas of unaffected 
skin intervening. The entire chest, back, and even shoulders may 
be covered by one diffuse patch, or an enormous area closely studded 
with perifollicular lesions may be seen. At times, only a few small 
spots are present. Occasionally, instead of the characteristic fawn 
color, elements of vivid rose modify the tint. Itching is rare. The 
face and neck are practically never involved. 

Course. Untreated, the disease persists indefinitely. 

Differential Diagnosis. Pityriasis versicolor usually has a 
characteristic appearance, and can always be definitely recognized 
by demonstrating the fungus. This is done by placing a scale on a 
slide, adding a drop of forty percent, potassium hydroxide, and heat- 
ing gently until bubbles form underneath the cover slip, which has 
previously been put in place. The scale, when examined with a 
number six objective with the light cut down, is seen to be filled with 
mycelia and spores. 

The conditions which the disease sometimes simulates are 
seborrhoea, freckles, vitiligo, maculo-anesthetic lepra, fading sec- 
ondary syphilis and ringworm. Seborrhoea is infiltrated, the 
scales are coarse and greasy; itching is often present; the face 
and scalp are usually involved. Freckles occur only on exposed 



INFECTIONS CAUSED BY FUNGI 241 

areas where tinea versicolor is never seen. In maculo-anesthetic 
lepra the general symptoms of the disease are present, but there 
is no scaling. Nor does fading syphilis scale, and there are other 
evidences of this disease, such as glandular enlargements, remains 
of a chancre, and the Wassermann reaction. In vitiligo the patches 
are white and surrounded by a hyperpigmented area. The reverse 
is seen in tinea versicolor. No desquamation is present in vitiligo. 
In ringworm the scalp is usually involved. On the body the scales 
are coarse and there are vesicles or pustules, features which are 
never present in pityriasis versicolor. The characteristic fungi of 
the one disease or the other further distinguish the two. 

Etiology and Pathogenesis. The disease is caused by a specific 
organism, the microsporon furfur. The fungus flourishes in a 
corneous layer in the shape of mycelia and numerous coarse spores. 
It is difficult to perfect cultures on artificial media. 

Treatment. Of the many methods of treatment employed it is 
necessary to mention but one because this one invariably succeeds. 
The patient bathes on three or four successive nights, and after 
bathing moistens his skin with a saturated solution of sodium hypo- 
sulphite. Before using the latter, dilute acetic acid may be dabbed 
on and dried off. 

Prognosis. The condition is always curable. Should it recur, 
the immediate resumption of treatment at the outset will stop the 
attack. 

Erythrasma is a closely related condition found on the genitals and 
extending thence to the neighboring regions. It is commoner in men than 
women, and also is seen in the axillae, below the breasts, and in the body 
folds of the adipose. The disease is characterized by a coppery, scaling, 
sharply marginated plaque and itches slightly, if at all. It is caused by 
the microsporon minutissimum, present in the scales, and is transmitted by 
contact with an infected person or with infected material. The treatment 
and prognosis correspond to what has been outlined in pityriasis versicolor. 
The disease must be differentiated from scaling dermatitis which desquam- 
ates more coarsely, itches, and may weep. It must also be differentiated 
from epidermophytia inguinale, a point which will be discussed below. 

Trichomycosis Palmellina is a condition of the axillary hairs caused 
by a growth on their shafts of colonies of fungi. The organisms impart a 
scarlet color to the hairs at their points of colonization. At times the pubic 
hair is involved. Fracture of the affected hairs may take place. The 
treatment consists in shaving off the diseased hairs and applying a mild 
bichloride solution to the shaved area. In certain tropical countries, yellow 
and black varieties of this disease are known. 

Piedra is a nodulation of the hair caused by minute concretions situated 
from one-half to one and one-half centimeters apart along the shaft. 



242 DERMATOLOGY 

These concretions are colonies of fungi, the trichospora, of which four 
varieties are known. The concretions are hard, fusiform or spherical, and 
are built about the hair with the latter as an axis. The condition must be 
differentiated from trichorrhexis nodosa (Chapter XXXIV) and monile- 
thrix (Chapter XXXIV). In the former there are no concretions, the 
nodes being due to local fractures of the hair with raveling of the cell 
strands. No organisms are demonstrable as in piedra. Monilethrix hairs 
present alternate constructions and fusiform swellings, so that the entire 
shaft resembles a minute rosary. The disease is a congenital and familial 
maldevelopment and not due to an infection. The most promptly efficacious 
treatment in piedra is to shave. 

Dermatomycoses. Dermatomycoses are diseases of the hairy 
or glabrous skin caused by the activity of parasitic fungi which 
attack the epidermis, derma, follicles, hairs, nails, or any combina- 
tion of these structures. They produce alopecia, temporary in most 
instances, permanent in favus. They are capable of provoking 
vesicular, pustular, or merely squamous eruptions, and some varieties 
produce follicular suppurations and granulomata. The fungi be- 
longing to this group fall into three varieties, — microspora, trich- 
ophyta, and achoria. The microsporon causes alopecia and 
squamous eruptions; the trichophyton causes these, but also may 
provoke pustular and granulomatous dermatoses; the achorion 
causes favus which produces permanent alopecia with atrophy, and 
on the glabrous surfaces, atrophy. Some varieties of the fungi im- 
munize against further attacks; others render the skin allergic. 
All of the organisms have spore forms, and thread forms or mycelia. 
In this book only the commoner varieties of this disease will be 
discussed. 

microspoeosis (fig. 46) 

Definition. Microsporosis is a disease, prevailingly of the scalp, 
leading to temporary alopecia and caused by a fungus with definite 
morphological and cultural characteristics. 

Symptoms. The disease is characterized by the appearance upon 
the scalp, chiefly in children, of bald patches (Fig. 46) up to two or 
three inches in diameter. These patches are covered by dirty gray 
scales, are circular or oval in outline, sharply circumscribed, and on 
closer inspection are seen to contain hairs broken off at the uniform 
distance of three or four millimeters above the level of the scalp. 
All the hairs in the involved area are affected. On attempting to 
extract them, they are found to come out without resistance, and 
when held so that they reflect the light, or against a dark background, 



INFECTIONS CAUSED BY EUNGI 243 

they are found to look a dusty gray. Near the large patches smaller 
ones are frequently observed, including half a dozen hairs. There 
may be very few or a great many affected sites. At times, on the 
glabrous surfaces of the body, are seen fugacious patches, yellowish 
and slightly scaly, resembling seborrhoea. They never scale or 
crust. Recently Lew endow sky reported cases in Hamburg in which 
kerion celsi, to be described below, was caused by this organism. 

Course. The disease usually begins from the age of five upwards 
terminating, when untreated, at puberty. It causes transitory 
baldness. 

Varieties. There are two varieties of the disease, that produced 
by the human microsporon, and that by microspora of animal origin. 
The former is the microsporon Audouini, the latter the microsporon 
lanosum, the source of which is domestic animals, notably dogs and 
cats. Rare varieties are the microsporon fulvum, equinum, and 
villosum. 

Differential Diagnosis, The diagnosis depends upon the clin- 
ical appearance, namely, the gray scales, gray, broken off hairs, 
presence of the disease in children, and the microscopic demonstra- 
tion of the fungi. Psoriasis (Fig. 20), seborrhoea (Fig. 25), and 
alopecia areata (Fig. 78) are to be differentiated. In psoriasis other 
and characteristic parts of the body are involved, the hairs rarely fall 
out, and the scales are thicker. The same holds true of seborrhoea 
which, on the scalp, is diffuse, itches, and in which the hair usually 
tends to fall. In alopecia areata there are no scales, a few hairs are 
present looking like exclamation points and they are not gray. In 
none of these three diseases are organisms found. 

Etiology and Pathogenesis. The disease is caused mostly by 
the microsporon Audouini, and lanosum, and exceptionally by the 
other forms mentioned above. The first is common in England and 
less so in other parts of the world, while microsporon lanosum is 
the commonest form in general. It is chiefly derived from cats and 
dogs, although transmission from person to person is very frequent. 
The fungi invade the follicles growing downward, and encasing the 
hair in a sheath, imparting the peculiar gray appearance to the hair 
noted in the symptomatology. Under the microscope the hair is 
found covered with a mosaic of spores, reaching from the broken 
end of the shaft down to just above the root. At this paint a few 
mycelia are found entering the shaft and forming Adamson's fringe. 
This fringe does not descend far enough to interfere with hair growth. 
The spores are always external. 



244 DERMATOLOGY 

On Sabouraud's maltose peptone agar medium the organism grows 
as a white or gray disc with a central button, and four or five radial 
depressions. The colony is white or grayish and tends to consist 
of concentric rings of increased and decreased density, imparting 
to the culture the appearance of a target. 

Treatment. In general practice the hair should be clipped, 
the scalp covered with a twenty-five percent, idodine in sixty per- 
cent, alcohol, the brown color thus emphasizing the lesions, and the 
involved patches should be epilated. Or four drams of idodine scales 
to an ounce of goose grease should be applied once a day until ex- 
foliation takes place. This often cures the patient. The best 
therapy in expert hands is a depilatory dose five Holzknecht 
units) of X-Rays, gauged by the Sabouraud Noire pastille, or by 
the Kieriboeck-Adamson method. By means of the Coolidge tube 
dosage can be measured without these means. In two to three 
weeks all the hairs fall and with them the fungi. Within six weeks 
a new growth of hair appears. 

Prognosis. The disease usually disappears spontaneously at 
puberty, and is always curable. 

TRICHOPHYTOSIS (FIG. 47) 

Synonyms. Ringworm; French, Teigne Tondante; German, 
Scherende Flechte. 

Definition. Trichophytosis is a disease manifold in its symp- 
tomatology, caused by fungi called trichophyta, of which there are 
many sorts. These micro-organisms provoke reactions in the hair, 
hair follicles, nails, epidermis and in the cutis. 

Symptoms. In general they are capable of causing alopecia 
(Fig. 47), destruction of the nails, squamous, vesicular (Fig. 48), 
pustular and granulomatous responses in the skin. The alopecia 
may be in circular (Fig. 47), oval, or irregular patches, and accom- 
panied by scaling vesicles or pustules. The nails may be broken, or 
just brittle and lustreless, with or without thickened and inflamed 
nail beds. The squamous, vesicular and pustular lesions are usu- 
ally inflamed, circular, and more or less infiltrated. The granulo- 
mata are fleshy, discoid, purulent lesions on the scalp or body. They 
may or may not itch. 

Course. The disease may occur at any age, all forms prevail- 
ingly attacking children, except the granulomatous and pustular 
varieties which attack adults equally, if not actually more often. 



INFECTIONS CAUSED BY FUNGI 245 

Untreated, the disease usually persists and gets worse, although not 
infrequently it may disappear of itself. 

Varieties. The regional varieties are trichophytosis of the scalp 
(Figs. 47 and 49), body (Fig. 48) and nails (Fig. 50). The clinical 
varieties are follicular, ungual, squamous, vesicular, pustular, and 
granulomatous. The varieties according to pathogenis are deter- 
mined by the type of the exciting organism. In point of fact, these 
purely artificial distinctions are practically not tenable, as alopecia 
may occur with either scaling, vesicles, or pustules, and granulomata 
may develop on the scalp or elsewhere, in the former eventuality 
causing at least temporary baldness. Pustular varieties occur any- 
where on the body. Vesicular or squamous dermatitis may be' sim- 
ulated. Thus, an enormous number of pictures is produced. 

We must here digress to discuss the simpler features of the 
trichophyta. These may flourish within the hair, or outside of it, 
or in both places. Those found within the hair are called endothrix, 
those without ectothrix, and those found in both places neo- 
endothrix. The ectothrix are again subdivided into a small and a 
large spored variety, and the entire classification may be represented 
as follows : 

Class Common Forms 

I. Endothrix Trichophyton Crateriforme 
(Spores and Mycelia within the 

hair) Trichophyton Acuminatum 

II. Neo-Endothrix Trichophyton Violaceum 
(Spores and Mycelia both within 

and without the hair, as a cuff) Trichophyton Cerebriforme 

III. Ectothrix 

(Spores and Mycelia within and 
without the hair and filling the 
entire follicle) 

A. Microsporon Trichophyton Gypseum 

B. Megalosporon 

1. True Trichophyton Rosaceum 

2. Favus-like Trichophyton Faviforme Album 



TINEA 

Trichophytosis capitis, or ringworm of the scalp, is also called 
tinea, or herpes tonsurans, tinea tondens, Scherende Flechte, Teigne 
Tondante. It occurs mostly in childhood as circular, oval or irregu- 
lar patches, often two centimeters in diameter, at times singly, but 



246 DERMATOLOGY 

usually disseminated. The affected surfaces may appear entirely 
bald, but on closer examination, either stumpy hairs are seen curled 
up in the scales, or long, fragile, lustreless hairs amidst vesicles and 
pustules may be present. The latter are arranged in simple or con- 
centric rings. At times, the hairs are broken off flush with the skin 
surface and they then look like comedones. All the affected hairs are 
easily withdrawn from their follicles. Seborrhoea may be closely 
simulated. Xo matter what disease is mimicked, however, the diag- 
nosis always rests upon the discovery of the organism. The pro- 
cedure is similar to that described in connection with microsporosis. 
The spores or mycelia are found, as the case may be, within or without 
the hair, or both. Several hairs must be examined, since some of 
them within the affected areas remain untouched, in this respect dif- 
fering from microsporosis, as well as in the circumstance that in 
microsporosis the hairs are broken off at a uniform level above the 
scalp. But when the connective tissue about the follicles is affected 
a disc-like granuloma, the kerion celsi, develops. This will be 
described, more fully in a subsequent paragraph. It is usually 
caused by some variety of endothrix, either the crateriform or 
acuminate. 

TRICHOPHYTOSIS CORPORIS (rlGS. 48 AXD 51) 

This designation is applied to trichophyton infections exclusive of 
the scalp, bearded area and nails. There are several clinical varie- 
ties determined partly by accidents of site, and partly by the strain 
of the organism. Except for mycologists, the second consideration 
is relatively unimportant. The different pictures are determined by 
the nature of the cutaneous reaction to the infecting agent. Thus, 
there are squamous, vesicular, pustular and papular lesions. Ere 
quently, body trichophytosis is associated with scalp or nail in- 
fections. 

The squamous ringworms are red. discoid, circular, or annular 
lesions, and when numerous or confluent become festooned. Tie 
entire surface may be scaling, or this may be the case only at the 
advancing margin. In other forms there is central scaling and 
peripheral vesiculation or pustulation. After the centre has 
healed and the margin has advanced, central recrudescences occa- 
sionally occur, giving the picture of concentric active vesicular or 
pustular rings. 

Papular ringworm is rare. It takes the form of lichenous lesions 
closely resembling lichen scrofulosorum (Chapter XXV). This 



INFECTIONS CAUSED BY FUNGI 247 

condition was first recognized by Jadassohn who named it lichen 
trichophyticus. The lesions consist of minute follicular elevations 
studded over the body. They are single or grouped as in lichen 
scrofulosorum, and sometimes itch. Their color is a waxy ochre to 
brown, and their pathogenesis is not clear. Always the lesions are 
associated with typical ringworm elsewhere. 

Unusual pustular ringworms are those resembling acne, and a 
peculiar granuloma, granuloma trichophyticum, first described by 
Majocchi. This disease occurs anywhere, chiefly on the back of the 
hands, and the starting point is an infective folliculitis from which 
spreads the furuncular infiltration. 

Eingworm often itches, and clinically it frequently simulates 
seborrhoea, vesicular or pustular dermatitis. The seborrhoeal type 
is squamous. The vesicular variety is of extreme importance for it 
looks like occupational, dishy dr otic (Fig. 51) and other types of 
circumscribed acute and chronic dermatitis. It may occur any- 
where on the body, but it is commonest on the hands and feet. It 
itches, and forms more or less inflamed circular or irregular vesiculo- 
squamous areas, in themselves often not in the least suggesting ring- 
worm. The organism may be recovered in culture, or demonstrated 
microscopically. Many of these cases are restricted to the interdig- 
ital spaces (Fig. 51), many are found on the palms and soles, and 
a discoid erythemato-vesiculo-pustular variety is found on the back 
of the hands and forearms. 

The clinical significance of this group of diseases lies in their 
similarity, as already stated, to vesicular dermatitis. Unless the fact 
is recognized and the correct diagnosis established, the condition is 
likely to be obstinate. Ivlany patients are thus indefinitely treated 
for a so-called chronic eczema. Quantitative blood and urine deter- 
minations are made, diets are prescribed, and the patient is enrolled 
as a victim of abnormal metabolism, when a strong solution of potas- 
sium hydroxide, a microscope, and a few tubes of Sabouraud's med- 
ium would furnish the correct diagnosis and a clue to proper therapy, 
albeit we should be deprived of the joys of pseudo-scientific pro- 
fundity. 

TRICHOPHYTOSIS BARBAE (FIG. 53) 

This form of ringworm is a suppurative folliculitis of the bearded 
region, and hence restricted to men. It is conceivable that hirsute 
women might be infected. It is also known as barber's itch and 
sycosis parasitaria, in contradistinction to staphylogenic folliculitis 
of the same area called sycosis non-parasitaria. Such distinctions 



248 DEKMATOLOGY 

are absurd, for whether the pathogenic agent is a bacterium or 
fungus it is a parasite. Thus, the one form should be called folli- 
culitis suppurativa trichophytica barbae, and the other folliculitis 
suppurativa staphylogenes barbae, since it is always a staphylococcus 
which provokes the latter form. (Chapter XXIII.) 

Folliculitis suppurativa trichophytica barbae is characterized by 
the presence of pustules which are inflamed, hard, often markedly 
infiltrated, and from the summit of which a hair projects. It is in 
and about the follicle containing this hair that the pathological process 
originates. Often several of the lesions coalesce into a large, lumpy, 
red patch. The entire bearded area, or only a part of it. may be 
involved. The process is to be distinguished from its staphylogenic 
cousin. In the latter there is less induration and the lesions are 
prevailingly smaller and more superficial. The final diagnosis, 
however, depends upon a determination of the presence of the fungi 
or bacteria, as the case may be. Iodides and bromides are capable 
of causing a pustular dermatosis in this region. Recognition of 
these conditions will depend largely on the history, and the absence 
of fungi in the hairs. Furthermore, in iododermata and bromoder- 
mata the lesions are less likely to confine themselves to the bearded 
area, and will be present on other parts of the face, neck and even 
body. 

Kerion Celsi (Fig. 49) has been alluded to twice. It is a pyo- 
genic granuloma usually caused by trichophyta, rarely by micro- 
sporon, and it arises on the scalp or in the bearded region as the sole 
manifestation of disease, or accompanying other co mm oner forms of 
trichophytosis. The lesion is a red disc, the surface of which is a 
granulated plateau oozing a thin, seropurulent fluid. It, too, must 
be differentiated from the halogen dermatoses as outlined above. 
Sporotrichosis and blastomycosis must also be excluded, partly on 
clinical grounds which will be mentioned below, and partly by la1> 
oratory methods as mentioned above, designed to demonstrate the 
pathogenic organisms. The disease responds readily to correct 
treatment, but without this may persist indefinitely. 

Trichophytosis of the Nails (Fig. 50) exists independently, or as- 
sociated with any of the other types of ringworm. It affects one or 
more fingers the nails of which are lustreless, brittle and often eroded, 
so that their surface is finely corrugated by vertical ridges. Between 
the nails and pulp of the fingers lies a dry mass of detritus. The 
nail bed is inflamed. Dermatitis, psoriasis and trophoneurotic dis- 
turbances of the nails must be excluded. The diagnosis is clinched 



INFECTIONS CAUSED BY FUNGI 249 

by finding the fungi in nail scrapings. The clinical points of dis- 
tinction are as follows: In dermatitis the nails are usually trans- 
versely ridged, but may be longitudinally, are less brittle, and not so 
lustreless, and other evidences of the disease are present. In pso- 
riasis, punctiform depressions are seen on the nails, as well as the 
general features of the disease elsewhere. In trophic disturbances 
the nails are distorted, rarely destroyed, and evidences of central 
nerve disease may be present. 

ETIOLOGY AND PATHOGENESIS OP RINGWOKM 

Ringworm is contagious and is transmitted by contact with in- 
fected people or animals, notably domestic animals, and chiefly dogs, 
cats and horses, The two sexes are equally vulnerable. Unques- 
tionably children are more susceptible than adults, but no age is 
immune. Trichophytosis barbae is often acquired in barber shops, 
but more frequently is found in people whose vocations or avocations 
cause close association with animals. Epidemics have been known, 
and from the fact that among those exposed not all are infected, it 
is obvious that predisposition plays an important role. To what 
extent this can be determined by modern immunological methods is 
questionable. Certainly people cured of kerion appear partly im- 
munized to subsequent infection. It would thus appear that deep 
trichophytosis is capable of producing a certain degree of immunity. 
This is certainly not so with superficial infections. It would appear 
then, that all statements with regard to the efficacy of vaccine treat- 
ment, percutaneous tests and complement fixation in superficial forms 
of ringworm must be regarded sceptically. Bruno Block's work on 
allergy seems significant, and it is not at all unlikely that the epi- 
dermis possesses some inherent quality of susceptibility as well as 
resistance to the fungi. In fact, this would seem obvious, but it is 
another matter to conclude that the entire host must react to a super- 
ficial pathogenic agent. The determining factor in all trichophyto- 
ses is the fungus. Different varieties cause different lesions, but only 
the common strains mentioned earlier in this chapter will be enum- 
erated. 

Trichophyton acuminatum causes alopecia. The hairs are broken 
flush with the skin surface, and one or more bald, discoid areas form, 
reaching a maximum diameter of two inches. About each hair is a 
minute papule. A rough resemblance to papular acne is presented. 
Similar patches may appear on glabrous surfaces. At times there 
are vesicles. 



250 DERMATOLOGY 

Trichophyton crateri forme causes gray, scaly, regular, round 
patches similar to those of microsporosis. There are long, healthy 
hairs among the diseased ones, however, and in the scales one finds 
many gnarled stumps of hairs containing the fungi which are of the 
pure endothrix type. This fungus is also capable of producing a 
vesicular eruption in circular plaques on the glabrous skin. 

Trichophyton- cerebriforms causes circinate, vesicular patches 
which may reach a diameter of two inches. The lesions are pink 
and impetiginous. Painful suppurative folliculitis of the beard is 
also produced by this organism as well as painful subcutaneous ab- 
scesses. Scalp ringworm, pink, bald, weeping and in numerous 
patches one to one and one-half inches in diameter, represent the 
clinical picture this fungus produces in children. 

Trichophyton violaceum causes tinea tonsurans, circinate, vesic- 
ular patches on the glabrous area, folliculitis suppurativa barbae and 
onychosis. 

Trichophyton gypseum presents two subvarieties, the asteroid and 
the radiolate. The asteroid produces pink, bald discs on the scalp, 
covered by small grayish scales. The hairs break off about one- 
quarter inch above the skin surface. Kerion is also produced, and 
on the glabrous portions vesiculopustuiar circular patches up to two 
inches in diameter. It also produces suppurative folliculitis of the 
beard. The radiolate variety produces similar lesions, as well as 
vesiculopustuiar ones with marked infiltration. 

Trichophyton rosaceum forms imperfect circles, the imperfection 
being caused by the efTacement of segments. The patches are dry 
and vary in size. In the bearded region plaques up to two inches 
in diameter form and the hairs are broken off one-eighth of an inch 
above the surface of the skin. A gray conical papule rises about 
each follicle. 

Trichophyton faviforme album forms lesions resembling pityria- 
sis rosea. 

Treatment. The Scalp. The object of treatment is to get rid 
of the fungi. This may be accomplished in two ways, either by 
destroying them with antiseptics, or by removing them mechanically 
by epilation. Many methods designed to accomplish both of these 
ends are contained in the literature. The best antiseptic is iodine 
in twelve percent, strength in goose grease or lanolin. This is 
rubbed in twice a day over the whole scalp until a dermatitis de- 
velops. Then, soothing ointments are applied. The process of irri- 
tating and soothing is alternated until the patient is cured. This 



INFECTIONS CAUSED BY EUNGI 251 

usually requires at least several months. Chrysarobin may be sub- 
stituted for iodine, and is employed in five to ten percent, strength in 
equal parts of glycerine and chloroform. The general management 
of the case is the same as with iodine. Sulphur, creosote and re- 
sorcin have also been employed. Sabouraud shaves the scalp and 
applies twenty-five percent, iodine in sixty percent, alcohol. Epila- 
tion is accomplished either by the use of forceps which takes long, or 
by employing the Roentgen rays, as described in microsporon in- 
fections. The hair falls in a fortnight and re-appears within six 
weeks. This treatment can be properly carried out only by experts. 

The Body. On glabrous portions of the body a cure can usually 
be effected in superficial cases within forty-eight hours by painting 
the patches with a ten percent, emulsion of chrysarobin in chloroform. 
After this the surface is coated with flexible collodion. A derma- 
titis develops, and the affected epidermis peels with the fungi. 

The Beard. The treatment is identical with that of the scalp. 
Suppurative trichophytosis in non-bearded areas and occasionally in 
bearded areas is best treated by removing the crusts and washing 
the skin. A daily light shave is necessary. Iodine salves are used, 
or the pustules are punctured with a fine cautery. Epilation is 
useful, but the best treatment is to employ the X-Kays as above. 

The Nails. Divulsion of the nails produces the quickest cure. 
If this is undesirable the nails should be scraped daily, and then 
immersed for a few minutes in a one percent, bichloride solution. It 
is also necessary to apply the medicament under the nail. This can 
best be accomplished by forcing a little cotton saturated in the above 
solution, or covered with a ten percent, ammoniated mercury oint- 
ment under the nail and keeping it there constantly. 

Kerion Celsi. This may be treated as the other suppurative forms 
are, but excellent results are produced by iodine cataphoresis. The 
negative electrode of a galvanic current, the sponge having been 
dipped in tincture of iodine, is applied to the lesions and held there 
for ten minutes, while a current of four milliamperes is allowed to 
flow. This should be done twice a week. Although the method is 
a trifle painful, the results are splendid, a cure not requiring more 
than three weeks. Similar results may be obtained with ten per- 
cent, aqueous solution of copper sulphate, the positive pole, however, 
being applied to the lesion. 

Prognosis. This is always good. 



252 DERMATOLOGY 

Special Forms of Tinea 

EPIDERMOPHYTIA INGUINAUS (FIG. 52) 

Synonyms. Eczema Marginatum, Tinea Cruris. 

Definition. Epidermophytia inguinalis is an infection chiefly 
of the perineum and genito-crural folds, caused by the epidermophy- 
ton inguinale. 

Symptoms. The disease occurs on the perineum and inner as- 
pects of the thighs. It is an exudative catarrh, bright red in color, 
with a raised, sharpened marginated, vesicular, circular border. 
The lesions group themselves in plaques which coalesce into broad 
patches over the sites mentioned, and extend often to the pubis and 
sacrum. At this stage the margin is convex or festooned, and the 
centre may be pale. Itching is often severe and this, as well as the 
inflamed color, are increased by sweating and friction. At times 
the axillae, breasts and navel are involved. Obstinacy and tendency 
to relapse characterize the disease. Whitfield, corroborated later by 
Ormsby and others, found vesiculopustular, interdigital, palmar, 
and plantar hyperkeratotic forms resembling dyshydrotic and acute 
vesicular dermatitis. Intense pruritus is a salient symptom of these 
special forms. The clinical aspects of this type vary in no wise 
from the picture of hyperhydrotic dermatitis or pompholyx. Great 
resistance to ill-adapted therapy is another feature, and still another 
is the acuity of its development, for sometimes within twenty-four 
or forty-eight hours on a hitherto healthy integument a full blown 
rash arises. 

Course. The disease persists indefinitely unless properly treated 
and ultimately leads to lichenification. 

Varieties. The varieties, as mentioned above, are the inguinal, 
including axillary and umbilical, and the exudative dermatitic form 
resembling pompholyx. This type is palmar and plantar, as well as 
interdigital. 

Differential Diagnosis. Pompholyx, ordinary dermatitis, and 
erythrasma must be differentiated. The first two look and act just 
like epidermophytia, and only the presence of the fungi, as demon- 
strated by cultivation, renders possible the correct diagnosis. Ery- 
thrasma is also a perineal disease, but there are no vesicles or rings ; 
rather, indeed, a diffuse, slightly elevated, sharply margined coppery 
plaque. This condition exists almost exclusively in men. The diag- 
nosis is clinched by demonstrating the microsporon minutissimum. 



INFECTIONS CAUSED BY FUNGI 253 

Etiology and Pathogenesis. Both sexes are attacked, men, 
however, more than women. Exposure in common carriers and 
hotels is an important factor. Excessive local perspiration predis- 
poses to the epidermophyton, and these facts, with the organism itself, 
comprise the important etiological moments of the malady. 

Treatment. The therapy is simple. Many methods have been 
employed, but usually only one, as suggested by Whitfield, is needed, 
for this is generally efficacious. 

Ex. Acid Salicylic 2 

Acid Benzoici 4 

Ung. Aq. Kosarum 

qs. ad 30 

Sig. 

This should be applied twice daily to the affected sites r and usually, 
at the most within ten days, the eruption begins to disappear. At 
times it causes a marked inflammatory reaction. Thus, a soothing 
ointment is indicated. Often, an erythema survives the original 
eruption for weeks, or even months. 

Prognosis. A cure is always possible under proper therapy. 

MISCELLANEOUS ANT) UNUSUAL FORMS OF TRICHOPHYTOSIS 

Dhobie Itch, Tinea Imbricata and Pinta constitute this group. There 
are also still rarer forms which need not be mentioned. Dhobie, or Washer- 
woman's Itch is a tropical disease, similar to epidermophytia inguinalis, 
and is caused by fungi unknown in our climate. Tinea Imbricata is an 
ichthyosiform, semicircular or circular eruption. It itches severely, and 
the broad scales are inbricated, get horny and curl at the edges. It is 
caused by an endodermophyton called by Castellani either the concentricum 
of indicum. The malady is non-inflammatory. Pinta is due to a pencil- 
lium and causes a generalized rash, preceded at times by systemic symp- 
toms. The lesions are polychrim, scaling, and the fading forms resemble 
parapsoriasis. 

favus (fig. 54) 

Synonyms. Tinea Favosa; French, Teigne Faveuse; German, 
Erbgrind. 

Definition. Favus is a fungus disease of the scalp and body char- 
acterized by the presence of yellow, saucer-shaped crusts or scutula, 
and leading to permanent alopecia with atrophic scars. 

Symptoms. Favus affects the scalp, nails, and glabrous portions 
of the skin. 

When the scalp is affected, minute red inflammatory papules are 
seen which, when punctured, give forth a puriform fluid. As the 



254 DERMATOLOGY 

papules grow they are surmounted by sulphur-yellow or lemon- 
colored, saucer-shaped structures, the concavities of which are upper- 
most, the convexities lying in the skin below the epiderm. It is this 
circumstance which causes the atrophic scar, for the connective tissue 
with the skin organs is permanently destroyed. The hairs in the 
involved area fall and the follicles are disorganized. The affected 
scalp has a peculiar mousy odor. The saucer-shaped crust is a pure 
culture of the fungus and is called a scutulum. In addition to these 
crusts are others formed in the usual manner through irritation and 
scratching. As the scutula enlarge and coalesce they form yellow, 
honey-combed bodies, the sulphur shade of which is often modified 
by dust, blood, ointments and matted hairs. The original color, how- 
ever, may be restored by swabbing off the affected area with alcohol. 
On removal of the crusts, a bleeding, depressed surface remains, its 
size determined by that of the crust. Such an area is entirely bald 
and always remains so. The aspect of a patient who has had favus 
is characteristic. The surviving hair remains in tufted patches of 
irregular outline in the midst of an otherwise denuded scalp which 
is adherent below, glazed, and irregularly scarred. 

Favus of the nails causes changes similar to those of tinea as 
described above. The etiological diagnosis is possible only by micro- 
scopic or cultural demonstration of the fungus. 

Favus of the body forms a fairly characteristic clinical picture. 
The glabrous portion of the skin is more or less studded with scutula 
sometimes to an extreme degree of generalization including the whole 
body. The scutula may coalesce, forming enormous plaques cover- 
ing the thigh, or the chest, or an entire extremity with high, honey- 
combed, friable, sulphur-colored crusts. Circular vesiculopustular 
lesions recalling ringworm may be seen. Although favus of the 
scalp may exist alone for years, frequently scalp, body and nail in- 
volvement may co-exist. 

Course. Starting gradually, the disease persists for an indefinite 
period, unless properly treated. It leaves the affected areas of the 
scalp permanently bald, and glabrous areas permanently scarred. 

Varieties. The clinical varieties are the body, nail, and scalp 
forms. The etiological varieties are the common type caused by the 
Achorion of Schoenlein, and the rarer types caused by the Achorion 
Quinkeanum or mouse favus, and the Achoria gallinarum, gypseum, 
and violaceum 

Differential Diagnosis. Active favus resembles ringworm, 
seborrhoea of the scalp and impetigo. Healed forms resemble lupus 



INFECTIONS CAUSED BY FUNGI 255 

erythematosus and pseudopelade or folliculitis decalvans. In the 
first group the yellow scutula are the distinctive feature. If the 
sulphur color is masked by dirt or grease, the alcohol swabbing as 
mentioned above will reveal the characteristic hue. Removal of the 
scutula discovers a roseate, superficially ulcerated, often bleeding 
area. The scutula examined microscopically are found to be com- 
posed of spores, and the involved hairs have spores without, and 
spores and mycelia within. Sabouraud also notes that, in boiling 
the hair up with hydrate of potash, a few bubbles of various sizes 
adhere to the shaft. The spores likewise vary in size. On Sabour- 
aud' s maltose peptone agar the colonies reach the size of a dime, 
are yellow, waxen, and honey-combed. Favus rarely, if ever, forms 
the rings and scales, and more rarely the vesicles and pustules, of 
ordinary ringworm. NTail favus clinically cannot be distinguished 
from ringworm of the nail. Only a microscopic or cultural differ- 
entiation is possible. Seborrhoea of the scalp causes no cicatrization, 
nor do scutula form in this disease. The crusts are greasy, never 
light yellow, and contain no fungi. The golden crusts of impetigo 
roughly simulate scutula, but the dried serum forms shiny beads 
until they become discolored, and no fungi are present. The favus 
scar differs from that of erythematous lupus in that it is firmer, and 
no other evidences of lupus are seen. The scars date back to a 
process which existed years before, and often the skin is bound down. 
Pseudopelade is found in discs like those of alopecia areata, and 
punctiform depressed scars are seen corresponding to atrophied fol- 
licles rather than to coarse ulcerations. 

Etiology and Pathogenesis. The cause is usually the Achorion 
of Schoenlein; rarely the other forms mentioned. The disease is 
highly contagious, and is most frequently seen in Russian Jews. 

Treatment. This corresponds to that of ringworm. 

Prognosis. A cure of the active process can always be effected, 
but the cicatrization and baldness it provokes are permanent. Thus, 
unless treated early and well, the prognosis as to cosmetic result is 
bad, 

BLASTOMYCOSIS (FIG. 55) 

Synonyms. Blastomycetic Dermatitis; Saccharomycosis ; Oidio- 
mycosis; German, Hefenmycosis. 

Definition. Blastomycosis is a partly cutaneous and partly sys- 
temic and cutaneous disease, the skin symptoms of which consist of 
the formation of purulent granulomatous and gummatous lesions. 
These are produced by either of two types of yeast fungi, saccha- 



256 DERMATOLOGY 

romycetes or oidiomycetes, each of which determines a relatively dis- 
tinct type of cutaneous reaction. 

Symptoms. Blastomycosis may be purely cutaneous. If so, 
ulcerations with vivid red borders arise, surrounded by acniform 
lesions at and near the margin. Both lesions form crusts upon the 
removal of which the ulcerating floor is exposed. A grumous green 
substance is secreted containing a crumby material. The pus, which 
is composed of leucocytes, epithelial cells, yeast fungi and even giant 
cells, is auto-inoculable and produces other lesions on the patient. 
It is always on exposed areas that the process begins. Osteomyelitis, 
pulmonary, hepatic and general systemic involvement may accom- 
pany the picture. 

At times the ulcers are numerous ; at times sparse. The charac- 
teristic features are the vivid margins, the secretion, the outlying 
acniform pustules, and often the floor fungates verrucously, forming 
vegetating granulomata of a purplish hue. The vegetations bleed 
easily, glisten, and give off a secretion precisely like the one de- 
scribed above. 

This description outlines the American variety of the disease first 
recognized by Gilchrist. Buschke, in 1894, described the first case 
of blastomycosis known to the world. The pathological work was 
done by Busse. The European variety had some of the features seen 
in Gilchrist's type, but began more as a subcutaneous gumma and 
abscess forming process which secondarily invaded the skin. This 
case was fatal. The Europeans consider their type of blastomycosis 
due to saccharomycetes, and the Gilchrist variety as due to oidiomy- 
cetes. The latter, our native form, is distinguished from the Euro- 
pean clinically by the fact that the acniform abscesses develop on its 
outer margin and are very minute, and by the further fact that the 
surrounding skin is inflamed in a manner suggestive of dermatitis. 
Hence, it is called blastomycetic dermatitis. 

In the systemic cases which resemble sepsis, plus the cutaneous 
features of blastomycosis, numerous ulcers appear all over the body. 
At times, both in the local and general forms, tremendous skin sur- 
faces are involved. When healing occurs, a pliable scar remains. 

Course. Only one lesion may appear, or several, or the entire 
body may be covered, many systemic cases giving the associated pic- 
ture of acute osteomyelitis, pneumonia, or sepsis. Early death may 
occur, or death may follow a long chronic illness, but many cases 
recover. 

Varieties. There are two forms of the disease, the European or 



INFECTIONS CAUSED BY EUNGI 257 

saccharomycosis, known as the Busse-Buschhe type, and the Amer- 
ican or oidiomycosis, known as the Gilchrist type. Symptomatically, 
there are local or systemic forms, and clinically, the ulcerating, acni- 
form and granulomatous types, all of which have been referred to 
above. 

Differential Diagnosis. An examination of the pus in all forms, 
or of sections, will reveal the nature of the disease. The fungi, 
double contoured, highly refractile bodies from ten to forty microns 
broad, are present. At times budding forms are seen. Sections from 
the lesions show a granuloma consisting of numerous abscesses, many 
of which are included in epidermal walls. Giant cells are usually 
numerous, but may be absent, and they contain the organisms. Clin- 
ically, the systemic forms must be differentiated from sepsis. This 
can be done by blood culture. The skin lesions should give the 
proper clue, and the necessary laboratory examinations should clinch 
the diagnosis. 

Tuberculosis, syphilis, sporotrichosis, and bromide and iodide 
rashes must be excluded. In all of these diseases the differentiation 
depends, in a large measure, tjpon the examination for fungi. 
Tuberculosis, save tuberculosis verrucosa cutis (Chapter XX Y) and 
syphilis never show small abscesses, the tuberculin and Wassermann 
reactions are positive, and in many forms tubercle bacilli are found 
in the tissue, while the pus never shows blastomycetes. Other evi- 
dences of both tuberculosis and syphilis are often present. Sporo- 
trichosis closely resembles blastomycosis, as to the lesions themselves, 
but their arrangement is usually striking in that they are chain-like, 
following the lines of lymphatic vessels in the involved regions. 
The sporothrix is easy to cultivate, and grows in heaped up, mucoid, 
gray or black colonies on almost all media ; while the colonies of the 
European blastomycosis are indefinite, light gray, yellowish, flat and 
sticky, and the colonies of the American varieties (of which there 
are several) grow in various ways, usually in discs. They are dry 
and covered by feathery-white hyphae. The halogen dermatoses 
closely resemble blastomycosis, and only the history of drug ingestion 
and the absence of fungi lead to a correct conclusion. 

It is almost impossible to confuse lepra with blastomycosis, but 
the differentiation would depend upon the discovery of either of the 
respective organisms of the two diseases. The deep forms of tri- 
chophytosis, namely kerion celsi and pustular ringworms, closely re- 
semble blastomycosis, and the differentiation here depends absolutely 
upon laboratory examinations. It is possible for breaking down 



258 DEKMATOLOGY 

sarcomas to resemble isolated blastomycosis lesions. In these cases 
only histological and pathological examinations will prevent error. 

Etiology and Pathogenesis. The disease is caused by a yeast 
fungus. The European variety is due to saccharomycis, a round, 
double contoured organism, whose diameter is equal to or twice that 
of a lympocyte. The centre is granular and basophile, the margin 
hyalin. It is often seen in the budding stage. The American vari- 
ety is due to an oidiomycis resembling the above, but often twice the 
former's size, and frequently associated with mycelia in the tissue. 
At first the Europeans considered the organism described by Gil- 
christ in the American variety as a contamination. In recent years, 
however, these doubts have disappeared. 

Treatment. Treatment is internal and local. The former con- 
sists of huge doses of the iodides, from one half drachm to two 
drachms three times a day. Local excision, cauterization, or the X- 
Rays should be used, if there is no prompt response to iodides. It is 
unnecessary to state that if no radical local measures are employed, 
in any case local antiseptic treatment is indicated. It is particularly 
in isolated or in sparse lesions that the X-Rays are of value. A 
Holzknecht unit, applied three times at weekly intervals should suf- 
fice. Another excellent method for local treatment is that of cata- 
phoresis described in connection with ringworm granulomas. 

Prognosis. Except in the rare systemic cases, of which only 
about ten percent, survive, the prognosis is good. 

SPOROTRICHOSIS ( SCHENCK-HECKTOEST ) 

Definition. Sporotrichosis is a cutaneous disease usually due to 
lymphatic involvement from a primary sore produced by a sporo- 
thrix. The lymphatic lesions include the skin by extension so that 
subcutaneous nodules, abscesses, and cutaneous ulcers and granulo- 
mata resembling tuberculosis verrucosa cutis are formed. The dis- 
ease is largely ascribed to de Beurmann of Paris. This is entirely 
unjust, as there is no question that Schenck preceded him by a num- 
ber of years, and it was only because of ignorance of the foreign liter- 
ature that the Parisians assumed priority, and it was due to the 
same cause that Americans permitted this. 

Symptoms. As a rule, a wound on the finger secreting a watery 
or serous pus appears. This develops into a granulomatous ulcer, 
not unlike a chancre. In the course of weeks or months swellings 
appear along the regional lymph vessels. These remain as sub- 
cutaneous nodules which are hard, somewhat tender, and vary in size 
up to that of a pigeon's egg. Some soften forming subcutaneous 



INFECTIONS CAUSED BY EUNGI 259 

abscesses. Both the nodules and abscesses may involve the skin, 
and irregular ulcers are formed. This is the form resembling tuber- 
culosis verrucosa cutis, and frequently small lesions in the neighbor- 
hood suggest tuberculides. 

The earliest lymphatic nodules feel like a cherry-stone imbedded 
in the skin. These grow, as mentioned above, and a fluctuating point 
develops, indicating abscess formation. The abscess presently rup- 
tures externally forming a fistula, the cutaneous margin of which is 
red or purplish and jagged. Very little infiltration surrounds the 
abscess so that its walls readily collapse. De Beurmann calls this 
form " sporotrichosis in multiple disseminated subcutaneous gum- 
mata." Another variety resembles ecthyma, and still another kerion 
celsL Involvement of the eye and lids has been noted in this coun- 
try. At times there are periosteal abscesses. 

Course. An acute form has been described. The majority of 
cases, however, are chronic, as mentioned above. 

Varieties. Clinically, the varieties are those included in the text, 
namely, the subcutaneous, lymphatic, abscess forms, verrucous, gum- 
matous, papulo-necrotic, granulomatous and ecthymatous. Etiologi- 
cally, there are several forms determined by one of the eight strains 
of organisms, the important ones of which are those of Schenck and 
HectJcoeriy and Beurmann and Gougerot. 

Differential Diagnosis. In the last analysis the diagnosis de- 
pends upon finding the organism. This is difficult to do except 
culturally, or by animal inoculation. The conditions to be excluded 
and the methods to be followed parallel those enumerated in blasto- 
mycosis. 

Etiology and Pathogenesis. The cause of the disease is a 
sporothrix. This organism grows in irregularly, mucoid, convoluted 
colonies on most media, but most luxuriantly on those containing 
sugar. Spores and septate granular mycelia characterize the minute 
appearance of the fungi. The organism is pathogenic to dogs, 
horses, mules and rats, and the serum of patients agglutinates the 
fungus, while reciprocal agglutination exists between sporotrichotic, 
and actinomycotic sera and the respective organisms. Likewise a 
positive percutaneous reaction can be produced in the sense of 
Pirquet. 

Treatment. Iodides are specific, and local treatment is surgical 
when abscesses have formed. 

Prognosis. With proper treatment the prognosis is invariably 
good. 



260 DEKMATOLOGY 

Actinomycosis, or " Lumpy Jaw," is a granulomatous, ulcerous disease of 
the skin of the neck and over the inferior mandible. The bones are 
primarily involved and the cutaneous manifestations are secondary. The 
lesions are lumpy, hard in spots, fluctuating elsewhere, red or purple, and 
in places pustular and ulcerated. From the ulcers pus exudes containing 
yellow granules which microscopically are seen to be composed of colonies 
of ray fungi. At times, in connection with pulmonary actinomycosis, 
cutaneous lesions similar to those described above are seen on the chest. 
Large doses of iodides cure many cases. Untreated or recalcitrant cases 
are fatal, death being due to inanition or chronic sepsis. 

Madura Foot, also known as mycetoma foot, morbis pedis entophyticus, 
endemic degeneration of the foot bones, etc., is a ray fungus disease of the 
foot, which is swollen, covered by abscesses, fistulae and granulomata, and 
the pus contains the mycetoma which Castellani has divided into yellow, 
black and red varieties, with fifteen sub- varieties. The disease is closely 
related, at least, to actinomycosis, and its treatment is identical therewith. 
Sometimes amputation is necessary. 

Coccidoidal infections are extremely rare and resemble blastomycosis. 

There remain two further forms of fungus infection to be described, 
which cannot readily be classified. One is Erysipeloid of Roseribach; the 
other Hairy Black Tongue. 

Erysipeloid is a mild inflammatory fungus disease occurring in people 
engaged in handling live animals, or their flesh. It is particularly common 
among fishermen. After some injury, a roseate, slightly indurated, edema- 
tous progressive lesion appears which suggests erysipelas, but which never 
becomes bullous. It is slightly painful, hot and tender, and its margins 
are not quite so abrupt as are those of erysipelas. (Chapter XXIII.) 
There are no chronic systemic symptoms, but occasionally the temperature 
rises a degree or so. The disease is probably caused by a streptothrix, one 
of the sub-varieties of discomycetes. It is harmless and readily cured by 
wet dressings. 

Hairy Black Tongue, the clinical features of which will be described in 
another chapter (Chapter XXXIX), is probably caused by a saccharomycis. 




Fig. 46. MICROSPOROSIS 

Note the circular, sharp areas of baldness. The scaling 
excludes alopecia areata ; and the lack of atrophy excludes 
pseudo-pelade and lupus erythematosus. Stumps of broken 
hairs project from the involved areas. 




Fig. 47. TINEA CAPITIS 

This is the large spore type of ring worm. The patches are 
irregular in size and shape; the hairs matted, irregularly 
twisted, and broken; and the scalp scaly or pustular. 




Fig. 48. TINEA CORPORIS 

The ringed outline is characteristic. The ring may consist of 
papules, scales or vesicles, each element always being minute. 
The color is light red, pink or buff, and at times there are con- 
centric rings. One or many lesions may be present and there is 
wide variation in size. 




Fig. 49. KERIOX CELSI 

This condition, otherwise called deep trichophytosis, is a granu- 
loma provoked by pyogenic trichophyta such as infest live stock. 
The lesions are elevated red discs resembling plateaus of granula- 
tion tissue. The hairs are gone, or loose, and droplets of pus may 
be expressed from the follicles. Tinea of the beard belongs in this 
group. 




Fig. 50. TINEA OF THE NAIL 

The nails are rough, pitted, lustreless and deformed. In psoriasis 
the nails show pin-point depressions, and in chronic dermatitis other 
evidence, elsewhere, of the condition exists. 




Fig. 51. DERMATITIS DUE TO FUNGUS INFECTION 

The lesions often, as is here shown, do not look like ringworm, but 
are like those of any other vesicular dermatitis. A great many cases 
of what is called pompholyx are caused by fungi. 




Fig. 52. EPIDERMOPHYTIA INGUINALIS 

The cause of this disease is a special fungus favoring the groin, perineum, 
scrotum, and at times the hands, feet, and even other areas. In the groin 
it produces the picture of tinea circinata, but by rapid extension patches 
form, as here shown. 




Fig. 



TINEA OF THE BEARD 



Hard., raised, purple, red or brown granulomatous masses, admixed with 
pustules, as shown on the chin, characterize this condition. 







Fig. 54. FAVUS 

The scalp shows cup-shaped saffron lesions; pure cultures 
lsewher~ 
baldness. 



r„fi where there are areas of atrophy. In this extensive case, there is complete 




&< 




Fig. 55. BLASTOMYCETIC DERMATITIS 

This disease varies in appearance. In America, 
the commonest form is here illustrated. It consists 
of numerous small abscesses, composing a vegetating 
mass as seen near the base of the thumb. The Euro- 
pean type more closely resembles kerion. 



CHAPTER XXIII 

STREPTOCOCCUS AND STAPHYLOCOCCUS INFECTIONS 
OF THE SKIN 

Streptococci cause impetigo contagiosa, ecthyma, erysipelas, solid 
edema of the face, and perleche. Staphylococci cause sycosis non- 
parasitaria, or simple sycosis, impetigo of Bockhart, ecthyma, fur- 
unculosis, suppurative hydrosadenitis axillarum, carbuncle, infec- 
tious eczematoid dermatitis, dermatitis papillaris capillitii and the 
pustular phase of acne. Both organisms cause phlegmon, suppura- 
tive paronychia and pyodermites. 

IMPETIGO CONTAGIOSA (FIG. 56) 

Synonyms. Impetigo. German, Eiterflechte. 

Definition. Impetigo contagiosa is a bullous dermatosis caused 
by a streptococcus (Fehleisen) which gains access to the epidermis 
through a solution in the continuity thereof. 

Symptoms. The disease may arise spontaneously but is usually 
secondary, depending on inoculation through a minute epidermal in- 
jury. At first a pink macule appears which changes with increased 
exudation to a bleb, the roof of which is so flaccid that it soon col- 
lapses. Thus the bullous stage of the disease is rarely actually seen. 
The contents of the ephemeral bulla escape and dry into an irregular 
crust formed of hardened drops of honey colored serum. The crusts 
may be brown from a rich admixture of blood, or dingy from dust, 
scales or grease. After a few days the crusts fall leaving a pink 
epithelialized area corresponding in size to that of the original lesion. 
Should the crust be forced off too early a pink superficially ulcerated 
surface is seen which soon becomes crusted again and heals without 
scarring. Often impetiginous surfaces weep freely. The patches 
may be small or as large as a dollar, discoid, gyrate or bullous. The 
disease is commoner in children than in adults. It occurs anywhere 
on the body and may be localized or general. Occasionally there is 
slight itching or burning. 

Course. The life of the individual lesion from onset to end is 

about ten days. Untreated, the disease may persist indefinitely. 

With proper care it is easy to curtail it. 

261 



262 DERMATOLOGY 

Varieties. Some of the varieties of the malady depend on purely 
artificial linguistic distinctions. Thus impetigo gyrata is a form in 
which there is peripheral extension and central healing. Impetigo 
bullosa is determined by a longer survival than usual of the bullous 
roof; otherwise it is precisely like the ordinary form. Impe- 
tigo bullosa may also gyrate if the margin advances and the center 
heals. 

An actual variety of the disease meriting special mention is the 
so-called pemphigus neonatorum, a poor name indeed since the dis- 
ease is no pemphigus but a bullous form of impetigo affecting the 
new born. 

Differential Diagnosis. Ordinary impetigo resembles no other 
skin disease. The bullous form simulates pemphigus (Fig. 17) from 
which it is to be differentiated by the nature of the crusts, by the pres- 
ence of an underlying cause and by the fact that impetigo lesions are 
seated upon an inflammatory base and are flaccid, while pemphigus 
lesions have a non-inflammatory base and the bullae remain tense for 
a longer time. Varicella is to be excluded by the presence of crops of 
lesions, many of which are papular, and by the umbilication of the 
pustules. Impetigo of the scalp sometimes resembles ringworm and 
a differential diagnosis can be reached only when trichophyta are 
demonstrated microscopically. 

Etiology. The one and only cause of impetigo contagiosa is a 
streptococcus. Everything written on the subject before, endeavor- 
ing to establish the pathogenic role of other organisms, is wrong. 
Staphylococci, ubiquitous on the skin surface, secondarily invade the 
pustules or crusts, but the exciting agent is always a special strepto- 
coccus. Predisposing causes are any itching dermatosis or any ves- 
icle which may become inoculated. Thus, herpes dermatitis, pru- 
rigo, urticaria, scabies, pediculosis, etc., may be the underlying factor. 
A most common cause is pediculosis capitis, particularly in children. 
Next to this comes scabies and prurigo. The disease may be trans- 
mitted from an infected individual to a sound one and is likewise 
autoinoculable. Thus nursing mothers acquire it from their in- 
fected babies. Nasal discharges and purulent otitis media often 
furnish the organisms. Lesions similar to impetigo contagiosa are 
produced by the Klebs-Loemer and pyocyaneus bacilli. 

Treatment. Volumes have been inspired by this topic and there- 
fore little need be said here. Above all, whatever the cause, re- 
peated recourse to soap and water in itself frequently determines the 
cure. A two to ten percent, ammoniated mercury salve applied to 



STKEPTOCOCCUS AND STAPHYLOCOCCUS INFECTIONS 263 

the lesions twice daily will cure the average case within a week. 
The crusts should previously have been removed with soap and water 
or olive oil. More persistent lesions should be painted daily with a 
twenty percent, solution of silver nitrate. Predisposing causes, nota- 
bly lice and scabies, should be removed. In impetigo contagiosa 
of the bearded regions in men, frequent application during the day 
of a two percent, solution of salicylic acid in dilute alcohol, and 
nightly applications of two percent, ammoniated mercury cream 
produce a prompt cure. 

Prognosis. This is always good. 

ECTHYMA (FIG. 57) 

Definition. Ecthyma is a pustular disease characterized by the 
formation of blebs which subsequently resolve into crusted ulcers. 

Symptoms. Either in conjunction with impetigo contagiosa, in- 
dependently thereof, or secondary to an itching dermatosis, blebs 
arise which soon exclude a brownish or yellow secretion. This 
rapidly dries into firmly adherent crusts which upon removal uncover 
a superficial ulcer, but deeper than in impetigo. The floor is bright 
pink, the margins less than one millimeter deep and the entire lesion 
is surrounded by a red zone which gradually fades into the normal 
skin. The ulcers are rarely larger than a dime, the areola is rarely 
broader than half an inch, making the entire maximum diameter 
about one and a half inches. About four weeks are required for 
the entire evolution and involution of the lesion which heals under 
the crust leaving a slightly depressed scar, at first pink and later 
white. At times the ulcers are gangrenous, in which event the re- 
sultant scars are large and more depressed. Many lesions may be 
seen, but as a rule there are only a few, and the disease tends to be 
restricted to the lower extremities and buttocks in children. Ten- 
sion, burning and pain are present but these symptoms are not 
marked. 

Course. The course of the disease coincides with the persistence 
of the predisposing factor. That of any lesion is about four weeks. 

Varieties. There are none. 

Differential Diagnosis. Ulcers with adherent crusts on the but- 
tocks and lower extremities of children suffering with impetigo or 
some itching dermatosis are usually ecthymatous. Only crusted 
syphilides are simulated, the latter being infiltrated and the Wasser- 
mann reaction being present. Impetigo itself differs from ecthyma 



264: DERMATOLOGY 

in its superficiality, this difference in degree constituting the only 
distinguishing feature between two diseases otherwise identical both 
in significance and causation. 

Etiology. The predisposing cause of ecthyma may be impetigo, 
pediculosis, scabies, prurigo, urticaria or any other itching derma- 
tosis. The exciting cause is the streptococcus. 

Treatment. The treatment is precisely like that of impetigo 
contagiosa. 

Prognosis. Xo difficulty is found in curing the malady if the 
underlying cause has been controlled. 

ERYSIPELAS 

Synonyms. St. Anthony's fire. German, Erysipel, Eothlauf. 
French. La Rose. Erysipele. 

Definition. Erysipelas is an infectious disease of the skin char- 
acterized locally by swelling, redness and heat of the affected parts, 
and by systemic reaction. 

Symptoms. Alter a prodromal period of two or three days dur- 
ing which malaise, loss of appetite, chilliness, chills and rigors may 
be present, a red spot appears on the skin near a previous injury 
such as a scratch, cut, surgical wound or upon the umbilicus in the 
newborn. The red spot increases in size, is swollen, glazed, hard and 
slightly tender, and sharply outlined by a steep margin terminating 
abruptly against the healthy skin. Xo outlying spots are seen. 
The original lesion progresses peripherally, maintaining the charac- 
ter already depicted and usually stopping at the hair lines. At 
times, bullae, vesicles or gangrene arise. At the end of a few days 
to a week the spot fades and the fever disappears fairly abruptly 
or lytic ally. The skin peels and finally becomes normal. 

Course. The course has been partly outlined above. At times 
rheumatic symptoms appear ; rarely, sepsis, nephritis, purulent otitis 
media, meningitis or local abscesses arise. A large proportion of the 
complicated cases end in death. 

Varieties. Acute, chronic, recurrent and ambulatory erysipelas, 
as well as solid edema of the face, constitute the varieties. Acute 
erysipelas has been described. Chronic erysipelas is a low grade, 
afebrile infection lasting weeks, months or years. Recurrent erysip- 
elas is rather a series of diseases than one disease just as recurrent 
coryza is not one disease. It represents a peculiar susceptibility. 
Ambulatory erysipelas differs from the common type in that the 
lesion spreads unboundedly while its older portions heal, thus trans- 



STKEPTOCOCCUS AND STAPHYLOCOCCUS INFECTIONS 265 

gressing the ordinary limitations characteristic of the malady. Solid 
edema of the face is a condition created by recurrent attacks of mild 
erysipelas maintained by a low grade of infection from a persistent 
source. Nasal fissures serve as an example. Ultimately a pro- 
ductive inflammation develops causing permanent dilatation of the 
lymphatics. 

Further forms of the disease are the nonsurgical and the surgical. 
Save for the latter, practically all varieties of erysipelas are facial, 
some nasal injury or disease, or a scratch, being the portal of entry. 
Surgical erysipelas develops near infected wounds anywhere on the 
body. 

Differential Diagnosis. The constitutional symptoms, the hard, 
glazed surface of the lesion, the characteristic margin and absence of 
outlying islands of infection are the diagnostic points. Acute derma- 
titis and facial zoster may resemble vesicular or bullous erysipelas. 
When the salient features of the disease are considered, however, 
confusion is unlikely. Chronic erysipelas resembles rosacea (Chap- 
ter XXXY) and a special form of lupus erythematosus (Chapter 
XXV), but other evidences of the latter rule out erysipelas. Rosa- 
cea is characterized by persistently dilated veins and less infiltration 
than erysipelas. 

Etiology. The cause of erysipelas is the streptococcus of Feh- 
leisen which gains access to the body through an abrasion of the skin. 

Treatment. When high fever is present the patient should be 
put upon salicylates with suitable stimulants in cases of cardiac de- 
pression. The local treatment consists of the use of wet dressings. 
For these may be employed Burrow's solution in ten percent, dilution 
applied as in the treatment of acute dermatitis (Chapter IX), or a 
hot saturated magnesium sulphate solution. If the former type of 
dressing is employed the fomentation should be continued without 
interruption day and night except when the procedure interferes 
with sleep. If hot wet dressings are employed, they should be ap- 
plied for fifteen minutes every hour, followed by a lotion of the 
calamine and zinc type. Such a lotion may also be used in con- 
junction with cold wet dressings if the latter are interrupted while 
the patient rests. The purpose of this treatment is simply to reduce 
the congestion. In general the cold fomentations afford more relief 
and work more rapidly than the hot, although isolated instances are 
encountered in which the latter seem better. After the inflamma- 
tion has subsided desquamation begins and any grease or oil over- 
comes the dryness of the skin. Icthyol ointment, iodine and similar 



266 DERMATOLOGY 

remedies have been employed, but they do little good, make the 
patient uncomfortable and have no rational basis. Anti-strepto- 
coccus serum has been used, but it possesses little that is commend- 
able. Isolation of the erysipelatous is as senseless, although it is 
still practiced, as the isolation of a patient with a streptococcous 
empyema, appendicitis or middle ear infection. Such cases are not 
segregated although the pus from these conditions is full of strepto- 
cocci. Ordinary asepsis will render erysipelas a safe disease from 
the standpoint of transmission. 

Complications of the disease have their special therapeutic indi- 
cations, a discussion of which has no place in a work on dermatology. 

Prognosis. Save in the aged, or in cachetic adults and babies, 
the prognosis is good. Complicated or hyperpyretic cases often end 
in death. 

Perleche. Perleche is a disease of the labial canthi in children, chiefly 
infants. It is a rhagadiform eruption of both commissures. A whitish 
film covers them and the process often spreads toward the mesial line of 
the lips and often extends to the skin. It is probably caused by the 
streptococcus plicatilis and can readily be healed by the use of silver 
solution and ammoniated mercury ointment. 

FOLLICULITIS SUPPURATIVA BARBAE STAPH YLOGEO^ES (PIG. 58) 

Synonyms. Sycosis; Non-Parasitic Sycosis; Sycosis Vulgaris; 
Sycosis Staphylogenes. German, Bartfinne, Bartflechte. French, 
Sycose. 

Definition. Folliculitis suppurativa barbae staphylogenes is well 
described by its name. Its most popular title, non-parasytic sycosis, 
is absurd for the staphylococcus is certainly a parasite. 

Symptoms. The disease usually begins acutely with an eruption 
of papules and pustules on the bearded region. It is thus commoner 
in men than in women or children. At times the pubis and axillae, 
and rarely the eyebrows and scalp, are involved. The lesions are 
follicular and perifollicular, a hair usually piercing the pustule. 
Upon withdrawing the hair a drop of pus is found adherent and a 
crateriform opening oozing pus remains behind. The lesions are 
often clustered and covered by crusts and the skin is thickened, red, 
uneven, itchy or painful. Thus the picture of pustular dermatitis 
is closely simulated. Successive crops occur. 

In long standing cases an atrophy develops, the skin becoming 
stretched over the malars, the cheeks being sunken below. This 



STREPTOCOCCUS AND STAPHYLOCOCCUS INFECTIONS 267 

imparts a skull like appearance to the face. At times there is 
permanent alopecia but this is unusual since, on the whole, the 
hair papillae withstand the process. 

When the scalp is affected, the process closely resembles pustular 
dermatitis. The disease is often associated with furunculosis. 
Coryza, both acute and chronic, not infrequently inaugurates the 
picture, or an injury, or otitis media or ordinary dermatitis, deter- 
mines the onset. 

Course. In general the disease is acute and is rapidly termi- 
nated by proper treatment. It may, however, become chronic, lasting 
months or years. The chronic form may be pustulo-papular or 
pseudo-atrophic as already described. 

Varieties. Some of the clinical varieties were mentioned in the 
previous paragraph. A form exists in which the pustules form a 
ring enclosing an atrophic center. This is called lupoid sycosis 
and by Unna was renamed ulerythema sycosiforme. 

Differential Diagnosis. The acute form resembles folliculitis 
barbae suppurativa trichophytica (Fig. 53), acne vulgaris and halo- 
gen acne. The fungus form is more indurated, often associated with 
other forms of ringworm and the fungi are demonstrable. Acne is 
not confined to the bearded areas and comedones are present. The 
iodide and bromide acne is more varicelliform and a history of drug 
ingestion may be elicited. 

Chronic forms resemble lupus vulgaris and lupus erythematosis. 
Lupus vulgaris, however, is less pustular, is cicatricial and not con- 
fined to the hairy areas. Lupus erythematosus is never pustular but 
scales, and in color is purplish. In fact, it is only in the atrophic 
stages that the two processes are similar. If no other evidence of 
either disease is present a correct estimation of the cause of the 
atrophy is almost impossible. 

Etiology. The immediate cause of the disease is the staphyl- 
ococcus pyogenes aureus or albus. Contributing causes are coryza, 
injuries, direct infection through combs, brutehes and razors at 
barber shops. In this, as in all pilosebaceous diseases, disturbed 
sugar metabolism is often present. It is obvious, since people once 
infected are readily reinfected, that there must be a predisposition. 

Treatment. The treatment of staphylogenic sycosis must be 
directed toward the predisposing and exciting cause. Thus, in 
cases following coryza, treatment of the nose is indicated. Patients 
who shave too closely must be cautioned, and if there is evidence of 



268 DEEMATOLOGY 

disturbance of carbohydate metabolism the starch and sugar intake 
must be limited and a suitable diastase administered. 

The local treatment consists of the removal of the pustules and in- 
fected hairs, the use of wet dressings, lotions and salves. The pus- 
tule may be opened with a comedo extractor, the hairs removed with 
depilation forceps, or if the involved area is extensive five Holz- 
knecht units of Roentgen rays should be given to cause depilation. 
The patient should also be directed to shave lightly once a day. 
When indicated, the employment of Roentgen therapy and iodine 
cataphoresis is valuable. The medicaments employed are either 
a two percent, salicylic acid and resorcin lotion in alcohol, sponged 
on several times a day and followed by talcum, or the use of very- 
weak bichloride solution either sponged on or used in the form 
of fomentations. At night a three percent, white precipitate or one 
percent, yellow oxide of mercury ointment may be employed. The 
patient must be warned that the lotions suggested may hurt for a 
few moments after their application. In the atrophic stage nothing 
can be accomplished by therapy. 

Prognosis. The average case can easily be cured. Now and 
then, however, great obstinacy is encountered, particularly when 
the disease depends upon a local predisposing cause such as coryza. 

IMPETIGO OF BOCKHAET 

For the sake of simplicity this condition may well be considered 
as a sub-variety of the preceding. The disease is a superficial fol- 
licular infection caused by staphylococci. It occurs anywhere on the 
body, at any age and in both sexes. It may be primary, but is 
often secondary to a preexisting and usually itching dermatosis. 
The affected areas are studded with minute pustules, many of which 
are pierced by lanugo or other hairs. The treatment need never be 
drastic. Usually the lotions and salves already mentioned in the 
previously described disease will promptly cure an outbreak. 

FUETTNCULOSIS 

Synonyms. Furunculus, Boil; French, Clou; German, Eiter- 
beule, Eitergeschwiir, Blutbeule. 

Definition. A furuncle is a staphylogenic infection starting in 
a hair follicle, about which a local cellulites develops which ter- 
minates in necrosis. A succession of such lesions constitutes furun- 
culosis. 



STREPTOCOCCUS AND STAPHYLOCOCCUS INFECTIONS 269 

Symptoms. At first a painful induration develops. This is 
red, feels hot, throbs, and is tender. It gradually increases in size, 
each of the above features augmenting, and often the neighboring 
tissue though not inflamed is edematous. The center softens as pus 
forms, and a yellow, ever increasing point develops. Frequently a 
hair pierces the center. Finally the abscess ruptures, pus which is 
creamy and yellow or blood tinged escapes, and after a day or two 
a necrotic plug follows. Thereupon the lesion heals, leaving a 
purple hyperemic patch which ultimately fades, the skin again be- 
coming normal in tint. A small scar remains if the slough was 
small, a larger scar if healing took place by granulation. The face, 
arms, body folds and neck are most frequently affected, but any 
area may be. Not uncommonly mild febrile symptoms accompany 
a developing boil, which vanish after its evacuation. 

Course. There may be a single boil, its life being no longer 
than ten days, or a series of boils giving the picture of furunculosis. 
Or there may be recurrent attacks. As a rule the cases are uncom- 
plicated, but occasionally sepsis with its usual features develops. 

Varieties. A variety of furunculosis is a disease of the axillae 
which does not originate in the hair follicles but in all other re- 
spects resembles the chronic form. This is hydrosadenitis sup- 
purativa axillarum, or abscesses of the axillary coil glands. This 
is a staphylogenic infection of the deep sweat organs and is extremely 
painful and often accompanied by profound systemic symptoms. 
There may be an associated axillary furunculosis of the hair follicle 
type. Etiologically, prognostically and clinically the two conditions 
are identical. 

Differential Diagnosis. A boil resembles nothing else save an 
infected cyst and the difference between the two is merely academic. 
Perineal furuncles simulate rectal abscesses from which they must 
be differentiated. It is possible for a boil to suggest the appear- 
ance of a chancre but the demonstration of spirochetes should pre- 
vent error. 

Etiology. The cause of furunculosis is the staphylococcus. 
The hair follicle and adjacent sebaceous glands are infected, the in- 
flammation involving the immediate connective tissue. Predispos- 
ing causes are diabetes, starch indigestion, hyperglycemia, inanition, 
infantile marasmus and weakness following serious illness. Local 
predisposing causes are itching dermatoses and excessive sweating. 
The latter is particularly the cause in the axillary form. 

Treatment. The treatment of furunculosis may be divided into 



270 DERMATOLOGY 

three objectives, the abortion of a developing furuncle, the cure of 
a developed furuncle and the control of the predisposing factors, both 
local and general. 

When a furuncle is developing abortion is possible in just one 
way, by the use of cold wet dressings. Any mild antiseptic may be 
employed, such as boric acid, aluminum acetate and very weak 
bichloride solutions, or the ice bag may be used. Wet dressings 
should be applied constantly, changed at short intervals and never 
be allowed to reach body temperature. They should be bulky and 
not covered by oiled silk or rubber tissue which prevent evaporation. 
The object of wet dressings in reducing acute inflammations of the 
skin is not widely enough understood. The coolness of the fomen- 
tations and the evaporation constitute their effectiveness, an aim 
that would be defeated by using impervious substances to cover 
them. Warm moisture favors the flourishing of the bacteria. 

When a furuncle has passed the abortable stage the treatment 
again has various objects, the first being to hasten the softening 
down, the second to favor evacuation of the abscess contents. To 
hasten softening, hot wet dressings are useful. They should be as 
hot as tolerable, without risking burns or scalds, and should be 
applied constantly until definite pointing has taken place. Hot 
flaxseed poultices are as good as wet dressings, and hot water bags 
applied over moist flannel are also excellent and simpler and cleaner 
than the hot poultices. Small furnucles may early be brought to 
complete softening by the use of twenty percent, salicylic acid, or 
soap and salicylic acid plaster. 

After the furuncle is soft it should be punctured with a sharp 
sterile toothpick, and such of its contents as flow out easily should 
be expressed with the gentlest pressure. Cold wet dressings should 
then be applied. Usually by the day following the puncture, but 
rarely later than two days after, even large furuncles will empty 
themselves and the necrotic plug or " core " will escape. There- 
upon prompt healing takes place. 

A furuncle should never be incised unless there is an associated 
lymphangitis with regional adenopathies, or unless there are marked 
systemic symptoms. Furuncles of the upper lip, however, should 
be incised early and freely as they are often dangerous. The time 
honored crucial incision for all furuncles is an anachronism, as 
the healing is slow, the scar unsightly and the method unwarrantedly 
drastic. In ninety-nine cases out of a hundred, simple puncture will 
suffice. 



STREPTOCOCCUS AND STAPHYLOCOCCUS INFECTIONS 271 

The general treatment of furunculosis consists first of removing 
the predisposing cause. Thus scabies, pediculosis, dermatitis and 
urticaria must be cured. Should filth be the cause, bathing must be 
urged. 

Removal of the general predisposing cause must be attempted after 
its nature has been determined. Thus gastric, fecal, blood and 
urine analyses should be made. In diabetes, gastric hyperacidity, 
starch indigestion and hyperglycemia, the indications are obvious. 
In marasmus, debility, post-febrile weakness, etc., general dietetic 
and tonic treatment will suggest themselves. 

The best general therapy for furunculosis lies in the use of 
staphylococcus vaccines. My own experience leads me to prefer 
polyvalent stock vaccines of which an injection should be given every 
five to seven days. The initial dose is four hundred million and it 
should be gradually increased to a billion. These injections are 
continued until a fortnight has elapsed without the appearance of 
new lesions. It is ideal to follow this by six fortnightly and six 
monthly injections. I have seen only one case fail to respond to 
this line of therapy within three months, or recur if the after treat- 
ment was sustained. Incidentally, a massive vaccine injection, 500 
to 700 million to a billion will often abort a developing lesion, or 
hasten its softening. 

Radiotherapy has its followers. The application of four Holz- 
knecht units of Roentgen rays will often cure the axillary form and 
diminish the sweat secretion. The Kromayer light is advocated 
by some. 

Prognosis. The prognosis of simple furunculosis is good. 
Furunculosis based upon diabetes is obstinate. When the upper lip 
is involved, or when there is systemic involvement, the cases not 
infrequently terminate in death. 

CAKBUNCLEi 

Synonyms. Carbunculus, Anthrax; French, Anthrax; German, 
Brandschwur. 

Definition. A carbuncle is an acute infection of a restricted 
area of the skin and subcutaneous tissue, larger, however, than the 
area occupied by a furuncle which it otherwise resembles. The 
name anthrax is misleading as it is never caused by the bacillus 
anthracis. 

Symptoms. Often the disease is preceded by marked systemic 
symptoms, malaise, chilliness, chills, rigors, fever or even hyper- 



272 DEKMATOLOGY 

pyrexia. Thereupon the lesion develops. It is first a hard, red, 
tender indurated mass, the size of a walnut or egg. Gradually 
softening takes place and pus exudes from one or more apertures. 
The involved area is undermined and the entire mass is cribriform, 
inflamed and fluctuating. A slough forms which escapes in toto. 
Healing is gradual and a large scar remains. As the local process 
wanes the systemic symptoms, often very severe, abate. Any part 
of the body may be involved but the disease is commonly manifested 
at the nape of the neck. 

Course. This may last from two to five weeks. 

Differential Diagnosis. Nothing else simulates carbuncle. 

Etiology. This parallels that of furuncle. Diabetes is a very 
common predisposing cause. 

Treatment. The treatment consists of wet dressings as in 
furunculosis, and wide incision and drainage. Ormsby favors the 
use of pure phenol injected into the mass. This causes a softening 
of the entire lesion. Vaccines are useless. 

Prognosis. This is good save in diabetes and in severe systemic 
complications. 

acne; vulgaris and dermatitis papillaris capillitii 
or acne keloid 

These, in their pustular phases, are analogous in their pathogenic 
significance to staphylogenic sycosis. Certain particular elements, 
however, come into consideration in these conditions which render 
it important to group them with seborrhea (Chapter XXXV). 
Thus their description will be deferred. 

Gayle. A rare special form of staphylogenic inflammation is caused by 
the staphylococcus hemorrhagicus. This disease is acquired by those en- 
gaged in flaying ewes which died of a peculiar puerperal infection. The 
human lesion is a slate colored bleb containing serum. 

Infectious Eczematoid Dermatitis is a disease characterized by many 
features of weeping dermatitis and exuding a seropurulent discharge. 
Ordinarily the illness arises in skin that has been bathed for a prolonged 
period in pus. Thus in patients with discharging otitis media or chronic 
purulent coryza the resistance diminishes in the skin constantly wet with 
discharge. A dermatitis (Chapter IX) is precipitated, the vesicles of which 
become infected, probably with an organism derived from the exciting 
purulent discharge. The skin is edematous, scaly, pruritic and often diffi- 
cult to heal. Its normal sites are the ears, scalp, lips, nose and cheeks. 
The treatment is a combination of that of acute dermatitis and impetigo 
contagiosa. 

Phlegmon and Pyodermas are caused either by the streptococcus or 




Fig. 56. IMPETIGO CONTAGIOSA 

The lesions of impetigo contagiosa are fragile bullae which rapidly rupture and crust, as 
on the upper lip. At times circinate progress of the margins occurs, as on the chin. On the 
left cheek is seen a recently ruptured bulla. 




Fig. 



ECTHYMA 



Ecthyma is impetigo contagiosa, but the lesions are deeper. 
They are caused by streptococci, and look like shallow ulcers 
which are crusted with dried blood or pus. The floor of an 
ecthymatous lesion is vivid red and moist. Ecthyma is due to 
inoculation by scratching, regardless of the cause of the itching. 




Fig. 58. FOLLICULITIS BARBAE STAPHYLOGENES 

This condition, otherwise known as simple sycosis, occurs as pustules about the 
beard follicles. When these rupture, crusts form. In trichophytic folliculitis, 
more induration is present. 



STKEPTOCOCCUS AND STAPHYLOCOCCUS INFECTIONS 273 

staphylococcus. The former is an infection of the subcutaneous tissue 
secondary to boils, carbuncles, erysipelas or any other infectious skin dis- 
ease. Cellulitis develops, and therapeutically the condition is surgical. 

Pyodermas, or pyodermites, as the French term them, constitute a loose 
concept implying the aggregate of all pustular skin infections due to the 
two common pyogenic cocci. Thus everything in this chapter is included. 
Often enough combined pictures are formed, such as axillary hydrocysta- 
denitis and furunculosis, impetigo and ecthyma, etc. 

Another variety of pyoderma not included in the text books is a rare 
form seen only in sepsis. Infarcts lodge in and below the skin. They 
appear suddenly, are painful, break down and suppurate, forming pustules, 
or furuncular lesions, or localized phlegmons. Their treatment is local 
and medical or surgical, as the case may be. The prognosis is one with 
that of sepsis. 

In this connection it may be added that anatomists, butchers, surgeons 
and those engaged in the care of the sick, or in trades involving the hand- 
ling of animal carcasses or their products, acquire infections known as 
dissection wounds, or post-mortem pustules. The lesions are not unlike 
those of gayle but are often serious, leading to cellulitis or sepsis. As a 
rule the staphylococcus or streptococcus causes the infection, but tetanus, 
anthrax or equinia may be similarly acquired (Chapter XXIV). 



CHAPTEK XXIV 

MISCELLANEOUS BACTERIAL INFECTIONS 

The miscellaneous bacterial infections of the skin are bacillary 
or coccygenic in origin, or of variable or presumptive bacterial 
causation. Those caused by bacilli are anthrax, malleus, diphtheria 
and rhinoscleroma ; that caused by a coccus is blenorrhagic keratc- 
derma; those presumably bacterial are granuloma pyogenicum and 
gangosa ; and those due to various bacteria are balanitis errosiva et 
gangrenosa and dissection wounds. Although all of these diseases 
are rare their importance is sufficient to warrant brief reference. 

ANTHRAX 

Synonyms. Malignant Pustule; French, Charbon; German, 
Milzbrand. 

Definition. Anthrax is an acute infectious disease, caused by the 
anthrax bacillus, which gives rise to a furuncle. The latter is a 
primary lesion and the starting point of a general sepsis. 

Symptoms. In from twelve to seventy-two hours after infection 
a macule develops. This rapidly becomes an itchy blister or bleb 
containing bloody serum. It breaks, crusts and is surrounded by 
a red halo near which satellite pustules arise. The lesion is stony 
hard and involves the deep tissues while an inordinate edema de- 
velops even as far as a foot away from the malignant base. Local 
adenopathies appear. At first there is low fever; later hyper- 
pyrexia. Often there are chills and the patient presents a picture 
resembling typhoid, sepsis or meningitis. Pus from the lesion, and 
often the circulating blood, contains anthrax bacilli. 

Course. The disease starts acutely. It ends in recovery if the 
process becomes localized. In this event the lesion behaves as would 
any furuncle. All cases in which sepsis occurs die within five to 
ten days. 

Varieties. There is but one form. 

Differential Diagnosis. The character of the lesion, the ex- 
tensive edema and the presence of the bacilli are the diagnostic 
points Ordinary furuncles may be simulated for at times they 

too cause a marked edema, and on the upper lip may prove to 

274 



MISCELLANEOUS BACTERIAL INFECTIONS 275 

be as serious as anthrax. Bacterial study will differentiate the 
two. 

Etiology. The cause is the anthrax bacillus. The mode of trans- 
mission is vocational ; hence herders, ranchmen, tanners and butchers 
are oftenest infected. Lack of asepsis in caring for the affected, or 
carelessness at operations or autopsies favor transmission. At times, 
unwitting contact with infected material or people suffices to convey 
the malady. 

Treatment. Early recognition of the disease is essential to suc- 
cessful therapy, if indeed the patient can be saved. Cauterization, 
or wide excision of the pustule are indicated and a specific serum 
exists which is efficacious. 

Prognosis. This is always serious. 

Equinia. Malleus, Farcy, Glanders; French, Farcin or Morve; German, 
Rotz. 

This is a highly infectious and usually fatal systemic disease with 
cutaneous manifestations. It is caused by the bacillus mallei. There are 
acute and chronic forms. The acute variety starts with some systemic 
manifestations, rigors, chills, diarrhoea, hyperpyrexia and, at the site of 
infection, an erysipelas-like surface which rapidly becomes bullous, pustular, 
or ulcerous. The discharge from these lesions, as well as from the tear 
ducts and nasopharynx, is full of bacilli. They are also present in the 
blood. Local glandular enlargement and lymphangitis are marked. The 
chronic variety starts acutely, or is indolent from the first. It resembles 
variola or pemphigus, the blebs often ulcerating and their discharge being 
highly infectious. The glands may remain unaffected. The cases are usu- 
ally fatal, the acute ones promptly so, while the chronic ones may drag on for 
months or even years. Therapy is of little avail and should be systemic. 

Diphtheria of the Skin. Cutaneous diphtheria occurs in two forms, 
either as an infection of wounds, or as a spontaneous condition. These 
forms are primary. Or, it may occur as a mild superficial infection by 
extension of nasopharyngeal or middle ear diphtheria. The primary form 
is characterized by an ulcer or gangrene coated with a diphtheritic mem- 
brane, and its clinical and prognostic significance parallel those of ordinary 
diphtheria. The secondar form resembles impetigo or ecthyma near the 
nose, mouth or external auditory canal and is seen chiefly in children who 
harbor attenuated Klebs-Loeffler bacilli in the respective secretions. Both 
the primary and secondary forms may give rise to eruptions resembling 
dermatitis herpetiformis or pemphigus. The primary variety is serious; 
the secondary type is not, though the bullous type, whether accompanying 
the primary or secondary form, may be serious. The diagnosis depends upon 
isolating the bacteria as one does in suspected pharyngeal diphtheria. The 
treatment is that of ordinary diphtheria, namely antitoxin injections. The 
best local agent is ammoniated mercury salve. A practical point to be 
emphasized is that in children with impetigo due to chronic coryza or otitis 
media a search should invariably be made for the diphtheria bacillus. 



276 DEKMATOLOGY 

Gangosa. This is a rare ulcerative granuloma of the nasopharynx. It 
is a tropical disease and presumably caused by a bacillus resembling that 
of diphtheria. 

RHINOSCLEROMA (FIG. 59) 

Synonyms, The term is -universal. 

Definition. Rhinoscleroma is a chronic infections granuloma of 
the nasopharynx, nose and lip, caused by the Frisch bacillus. 

Symptoms. At first small nodules appear on the septum of the 
nose. These increase in number and size until a diffuse, elevated, 
hard mass develops involving the entire nose, adjacent portions of 
the lips, often all of the structures of the mouth and the pharynx. 
A stony hardness arises and the mass, though painless, is tender. 
Its color is ivory white, red or purple and its surface is glazed and 
often vascular. - 

Course. This is slow and chronic, extending over years. 

Differential Diagnosis. The lesions remotely simulate tuber- 
culosis, gumma and sarcoma. Tuberculosis is excluded clinically by 
the absence of ulceration, by the hardness of the lesion, its ex- 
tent, absence of tubercles and absence of the tuberculin reactions. 
Syphilis is excluded by the first two features and tbe absence of the 
"Wassermann reaction. These two diseases with sarcoma, which 
clinically may closely resemble rhinoscleroma, are further excluded 
by histological examination. A section of rhinoscleroma presents 
the microscopic features of an ordinary granuloma plus three path- 
ognomonic traits, the presence of the bacilli, Mikulicz's cells and 
Russell's bodies. The bacilli are elongated, encapsulated organisms 
clustered either in the collagen fibers or in structures known as 
Mukulicz's cells. The latter are frothy areas taking a light stain, 
and they are two or three times the diameter of a lymphocyte. 
They have no nuclei and are probably small lymphocytes filled with 
bacilli. Russell's bodies are circular hyalin end products of colla- 
genous degeneration, and although found in many other skin lesions, 
they are most numerous in rhinoscleroma. 

Treatment. X-rays, excision and plastic surgery constitute the 
modes of attack. 

Prognosis. The disease, though slow and benign, is usually in- 
curable and if temporarily controlled is likely to recur. Death, in 
extreme instances, is not due to the disease itself but to stenosis caused 
by the mass in the upper respiratory passages. 

Etiology. The Frisch bacillus causes the disease, most cases of 
which have arisen in south-western Russia. 



MISCELLANEOUS BACTEKIAL INFECTIONS 277 

Balanitis Errosiva et Gangrenosa is an unusual inflammation of the 
prepuce and glans which travels thence phagedenically. The ulcer is un- 
dermined, has a granulated surface and shows no tendency to heal. It is 
possibly caused by a Vibrio, but possibly by a spirochete of which the 
Vibrio is a stage or phase. It may be obstinate but usually is cured by 
hydrogen peroxide, since the exciting agent is an anaerobe. Although 
the disease is in the main venereal it may develop upon surgical wounds. 

Nosocomial Gangrene or Noma is a buccal gangrene which usually 
follows measles. (Chapter VII.) 

KERATOMA BLENORRHAGICUM 

Definition. This disease is characterized by the formation of 
hyperkeratotic lesions in gonorrheal subjects. 

Symptoms. There are local and generalized forms, the latter 
being the rarer. The lesions are minute, isolated or confluent, yel- 
low or yellowish waxy pustules mainly found upon the leg and 
foot. A dense scale surmounts them and their arrangement sug- 
gests a relief map. Usually they accompany arthritic types of 
gonorrhea and often develop under immobilizing dressings over the 
joints. 

Course. The disease is an intercurrent phenomenon of gonor- 
rhea and disappears with the latter. 

Varieties. The local type affects the hands, feet and nails, spar- 
ing the palms and soles. The general type appears anywhere except 
on the head and neck, but favors the legs and forearms. 

Differential Diagnosis. A papular, horny dermatosis in a 
patient with gonorrhea is likely to be blenorrhagic keratoma. 
Syphilis and psoriasis may be simulated, but the absence of the 
Wassermann reaction and adenopathies and the history of the case 
exclude these two diseases. 

Etiology. Gonorrhea is a causative element although the gon- 
ococci have not yet been found in the lesions. It is held by 
many that the casts employed for gonorrheal arthritis have much 
to do with the development of the lesions. 

Treatment. The treatment is that of gonorrhea and the local 
use of resorcin or salicylic acid creams or lotions. 

Prognosis. A cure is always to be expected. 

GRANULOMA PYOGENICUM (FIG. 60) 

Synonyms. Bothryomycosis, Pseudo-Bothryomycosis, Granuloma 
Telangiectaticum. 

Definition. This is a disease characterized by pedunculated 



27S DERMATOLOGY 

tumors from one-fourth to one-half an inch in diameter which arise 
upon a previous injury. 

Symptoms. In the early stages the tumors are red. moist and 
painless. They look like granulation tissue, are crimson, bluish or 
brown and though usually lentil shaped or roughly spherical, they 
may be flattened down like mushrooms. As a rule there is but one 
tumor. It secretes a foul, seropurulent matter and the surface 
may be smooth or contain pus filled crypts. At times the lesion 

iMes a raspberry. The Angers, toes, hands, fe- 
cheek, umbilicus, back and shoulders are the favorite si:—. 

Differential Diagnosis. Papillomata when inflamed or ulcer- 
ated resemble granuloma pyogenicum. A microscopic examination 
would clear this up as the lesion has the structure of granulation 
tissue. 

Etiology. An injury precedes the lesion. Presumably it is an 
infectious granuloma caused by an unidentified organism. At first 
is was regarded as a human form of bothryomycosis. but this view 
has been abandoned and the majority of writers agree, although 
without final proof, that the staphylococcus aureus is at fault. 

Treatment. Excision and cauterization of the base, or the 
Roentgen rays will cure the disease. 

Prognosis. The prognosis is good and although the lesions may 
recur they can always be ultimately cured. 




Fig. 59. RHINOSCLEROMA 

As a rule the nares, tip of the nose, and areas adjacent to the nose 
show a stony hard, white or reddish tumor, with the type of nasal dis- 
tortion here shown. Sarcoma is often suggested, and a histological exam- 
ination may be required in order to make the correct diagnosis. Syphilis 
and tuberculosis must also be ruled out. 




GRANULOMA PYOGENICUM 



The lesion is a bright 
pedunculated or sessile. It i 
and is more frequently encounter* 



red. raspberry-like, glistening tumor, either 
actually a small mass of granulation tissue, 
the fingers than anvwhere else. 



CHAPTEE XXV 

TUBERCULOSIS AND LEPRA 

Tuberculosis and lepra are bacteriologically closely related 
diseases, in that the respective causes, the Koch and Hansen 
bacilli, have many features in common. Morphologically and in 
their standing affinities they are similar. Culturally they differ. 
The type of cutaneous reactions they evoke are not unlike. On the 
other hand, lepra has two clinical bonds with syphilis, the appear- 
ance of many of the lesions and the fact that in tubero-nodular 
lepra the Wassermann reaction is often present. It is manifest from 
the foregoing that the two diseases in question and syphilis can 
cause the utmost confusion, both as to their gross objective charac- 
teristics and as to some of their subtler ones. 

Skin tuberculosis is in many respects a most puzzling malady. Its 
range of cutaneous reactions is wide, and the mechanism in their 
production is most varied. It is a disease almost as protean in 
its manifestations as syphilis and it is far less understood although 
perhaps nearly as important. The lesions are caused either by viru- 
lent tubercle bacilli, attenuated tubercle bacilli, or by bacillary toxins. 
Thus there seem to be two great groups of lesions : those which are 
actually infective and those which in their response to toxins are in 
effect allergic reactions. The latter are thus natural phenomena 
of which the von Pirquet reaction is the artificial replica. As our 
knowledge of the subject increases an ever greater number of 
pictures is being removed from the group of toxic tuberculosis into 
that caused by the bacteria. There is a further class of conditions 
not definitely toxic in origin but which, because of certain circum- 
stantial points, are included with tuberculosis. 

The details of these matters will be discussed in later passages. 
It is necessary, however, to bring out one more general point here. 
Those forms of cutaneous tuberculosis not considered as immediately 
bacterial are called tuberculides. The term is unfortunate for its 
significance is inconsistent with that of the word syphilide as 
applied to syphilodermata. A syphilide is a cutaneous manifesta- 
tion immediately due to the causative organism of syphilis. A 

tuberculide, however, is precisely not a lesion caused by the tubercle 

279 



280 DEKMATOLOGY 

bacillus, but provoked by the latter^ toxins, or perhaps only re- 
motely connected with tuberculosis. This contradiction in usage has 
become customary and the terms are so securely intrenched that 
we must make the best of it and accept them. Thus we divide cuta- 
neous tuberculosis into three groups: first, true or bacillary tuber- 
losis; second, toxic or presumably toxic tuberculosis, namely the 
tuberculides; and third, tuberculides of presumptive tuberculous 
nature. A fourth group might be added, namely, diseases which 
have not been suspected of having a tubercular etiology, but the 
minute anatomy of which suggests tuberculosis. The diseases them- 
selves may be classified as follows, according to the foregoing sketch. 

A. Infective Tuberculosis. 

I. Massive Granulomata. 

1. Lupus Vulgaris. 

2. Tuberculosis Verrucosa Cutis. 

3. Scrofuloderma. 

II. Tuberculosis Milaria et Ulcerosa. 

1. Tuberculosis Ulserosa Miliaris. 

2. Tuberculosis Ulcerosa (not miliary). 

3. Tuberculosis Miliaris Propria Disseminata. 
III. Lingual Tuberculosis. 

B. Non-Infective Tuberculosis. Tuberculosis of toxic origin, and 
dermatoses associated with tuberculosis. 

I. Tuberculides. 

1. Lichenoid Types. (Lichen scrofulosorum.) 

2. Papulonecrotic Types. (Acnitis, folliclis, acne neuro- 
tica, acne cachecticorum.) 

3. Lupus Erythematosus. (Discoid, disseminated or ex- 
anthematous. ) 

4. Sarcoids. (Boeck, Darier-Boussy, etc.) 

5. Erythema Induratum, Bazin. 
II. Presumptive Tuberculides. 

1. Pernios. 

2. Pityriasis rubra (Hebra). 

3. Angio keratoma (Mibelli). 

4. A vague group resembling Malcolm Morris' follicular 
" eczema." 

C. Diseases sometimes histologically resembling tuberculosis. 

1. Lichen nitidus. 

2. Granuloma annulare. 



TUBEKCULOSIS AND LEPRA 281 



INFECTIVE! TUBERCULOSIS 

In dealing with this subject, the order hitherto followed in the 
individual diseases will be slightly modified. Therapy will be con- 
sidered separately in connection with the two subdivisions, massive 
and miliary tuberculosis. 

The massive granulomata are voluminous, destructive and ulcer- 
ative. The miliary granulomata are small, more superficially de- 
structive and likewise ulcerative. The latter group tends, on the 
whole, to be more serious from the standpoint of life and health. It 
is necessary, however, to grasp the fact that the distinctions enumer- 
ated are in no sense fixed and that they are artificial to the extent 
that they conform with fact only in a majority of instances, while the 
minority form a borderline which is not distinct. 

This overlapping is due to the fundamental truth that the basic 
feature in all tuberculosis is the tubercle, running just as true to type 
in the skin as in the lungs. If the skin and lungs were inter- 
changed, miliary cutaneous tuberculosis would be miliary pulmonic 
tuberculosis ; lupus vulgaris, tuberculosis verrucosa cutis, and tuber- 
culosis fungosa would be tubercular pneumonia; ulcerative forms 
would produce cavities or abscesses. The anology need be pursued 
no further. 

Certain broad principles apply in diagnosing skin tuberculosis. 
In the first place, evidences of the disease elsewhere should be sought. 
Thus a careful, general, physical examination should be made, es- 
pecially of the lungs and lymph glands. The tuberculin test should 
be made, particularly the hypodermatic injections, as the von Pir- 
quet and Moro procedures are of little value. A negative von 
Pirquet test has some significance but the Moro test has none, whether 
positive or not. Often, by the first method, a local reaction appears 
in the lesion which becomes redder and more swollen. Syphilis is 
excluded by the Wassermann test. 

The methods by which the lesions themselves are differentiated 
from those which simulate them are by inspection, microscopic ex- 
amination and animal inoculation. Inspection will be dealt with 
further on, for clinical dermatology is indeed but the science of 
refined and astute inspection. Microscopic study is directed to 
the anatomy and bacteriology of the lesion. The anatomy is that 
of tuberculosis elsewhere. Frequently, however, tuberculosis looks 
like syphilis in its minute as well as gross anatomy. In all forms 
of tuberculosis the bacilli are present except in lupus vulgaris where 



2S2 DEKMATOLOGY 

they are hard to find. The biological test is of great value as it 
is frequently positive. If some of the suspected tissue is intro- 
duced into the peritoneal cavity of a guinea pig, the latter nearly 
always develops tuberculosis. 

LUPUS VULGARIS (FIG. 61) 

Synonyms. Lupus tuberculosis. Lupus of Willan. 

Definition. Lupus vulgaris is a form of chronic cutaneous 
tuberculosis originating in small foci. These foci, or lupus nodules, 
tend to invade large areas, forming flattened patches in which there 
is slight if any softening. 

Symptoms. The characteristic feature is the above mentioned 
nodule which is a translucent speck in the skin, and about the size 
of a pinhead. The color is yellow, the shade being that of honey, 
apricot or apple jelly and the lesion resembles a small particle 
of one of these substances imbedded under the epidermis.* The 
speck is clean cut, rounded and the skin near it is normal, or a trifle 
shiny. On palpation nothing is to be felt save a subtle density 
of the skin when gently pinched up. When such a lesion is punc- 
tured by a small blunt sound, the affected point is felt to be 
boggy and soft and the sound encounters no resistance. A drop 
of blood quickly gathers and when removed it leaves a small hole 
behind it where the nodule was. If the skin is rendered bloodless 
by pressure with glass, the nodules stand out clearly against a white 
background, their jelly-like appearance becoming more pronounced. 
This procedure overcomes the blurring of the picture by hyperemia 
about the nodules which, though usually slight, suffices to conceal 
their characteristics. 

As time goes on more and more nodules appear forming plaques. 
ISTow more inflammatory elements enter the picture and the entire 
affected area becomes red, humid and inelastic. Such a plaque 
varies in shape and size and even elevation. Scaling occurs and 
often slight softening. Regressive changes set in and a scar forms, 
for the process causes a loss of substance unimaginably profound 
considering how superficial the elemental lesions look. There may 
be an annular or serpiginous arrangement of the nodules, the center 
healing. At times ulcers or crusts develop forming rupial or 
ostraceous lesions. Irregular scars remain within which new 
nodules often develop, reinaugurating the process. 

The scars are white, livid, reddish or red, and beyond them, as 
beyond all types of tuberculous lesions, fresh nodules are often found. 



TUBEECULOSIS AND LEPEA 283 

More voluminous forms than those mentioned, are known, giving the 
picture of lupus tuberosus, prominens, nodosus or tumidus, or, if 
they ulcerate, the picture of lupus exedeus. The ulcers may vege- 
tate, giving the picture of lupus vegetans or verrucosus. From the 
scars skin horns may arise and not infrequently great mutilation of 
tissue takes place, creating lupus mutilans. 

It is necessary to mention these descriptive varieties since the af- 
fixed adjectives eliminate lengthy disquisitions, albeit it would be re- 
grettable for the reader to assume that these varieties are funda- 
mental. 

Fully four-fifths of all lupus attacks the face and in one-half of 
the cases the lesions are found on the nose or near it. Three-fourths 
of the patients present involvement of the nasopharynx. The lips, 
eyelids, ears, even the drums, are often involved. ISText to the face, 
the upper extremities are the most frequent site affected, while the 
lower extremities and other areas of the body are seldom involved. 
The portion of the nose favored by the process is that proximal to 
the cartilaginous area. The softer parts often entirely disappear 
leaving a small beak. Fingers or toes, and rarely the hand or foot, 
may be mutilated to the point of spontaneous amputation. 

Lupus of the mucosa appears in all the forms described on the skin, 
but prevailingly in nodules within the nares, less often anywhere 
else in the buccal orifice. Destruction of the lips from within or 
without converts the mouth into a rigid slit, and a process on the 
eyelids produces a like effect upon the palpebral orifice. Involve- 
ment of the conjunctiva causes pannus and even destroys the sclera. 

There are very few subjective symptoms, except such as might 
be ascribed to rhagades or deformities. At times there are fever, 
bronchitis, amyloid degeneration, pulmonary, laryngeal, bone and 
gland tuberculosis. As a rule the disease starts in youth, is more 
frequent in women than in men, and is found in the slums, particu- 
larly in Southern Europe where it is a common disease. There is, 
however, a great deal of lupus in the Scandinavian countries and in 
India. 

Course. The disease tends to begin in early youth or childhood, 
but may arise at any age, and usually lasts for years. It cicatrizes, 
and more rarely ulcerates before doing so. Isolated patches may 
heal of themselves. Very frequently lupus is the starting point of 
visceral tuberculosis. In this event death occurs earlier than it 
would from lupus alone. Indeed, in uncomplicated lupus death is 
rarely due to tuberculosis. 



284 DEEMATOLOGY 

As to the lupus lesions themselves, their spread is most gradual. 
It may occur by local extension, or extension via the lymphatics. 
In the former case great plaques are formed which spread peri- 
pherally and heal or break down centrally. In the variety which 
spreads through the lymphatics, a mother lesion is noted, and nearby 
smaller daughter lesions. In widely disseminated lupus the distri- 
bution occurs through the blood current's agency, and far flung 
lesions are scattered over the skin. This is the style that most 
frequently involves the viscera. The lesions may persist unhealed 
forever, or scar over, or ulcerate, or become the site of repeated 
attacks of erysipelas. Recurrences may take place in the scars, and 
the latter may be the site of epithelioma. The disease may persist 
from youth to old age, and in mild cases the patient remains in com- 
paratively good health. 

Varieties. In addition to the descriptive varieties enumerated 
above, there are lupus miliaris, lupus pernio, lupus vulgaris erythe- 
matodes, lupus tumidus, and many other even rarer varieties. 

Lupus miliaris is a mildly disseminated form, one of the well 
known synonyms of which is acne telangiectatica. It occurs chiefly 
on the face and consists of disseminated nodules. It arises sud- 
denly and progresses in successive crops. It may involve the body 
extensively and often accompanies tuberculides. 

Lupus pernio clinically resembles pernio and anatomically tuber- 
culosis. Formerly it was considered a variety of lupus erythe- 
matosus. It comes on the nose, cheeks, chin, fingers, toes, and 
ears. Its cause is obscure. 

Lupus vulgaris erythematodes clinically simulates lupus erythe- 
matosus and histologically tuberculosis. Lupus nodules are present. 
Lupus tumidus is a voluminous involvement of the ear lobe or lobes 
and causes a swelling studded with lupus nodules. 

Differential Diagnosis. Lupus vulgaris must be differentiated 
from lepra, syphilis, blastomycosis, sporotrichosis, lupus erythema- 
tosus, sarcoid, erythema induratum of Bazin, and papulo-necrotic 
tuberculides. The first three are diseases of a different etiology 
from lupus. The remainder constitute a group, the differentiation 
of which is largely academic, since they, as lupus, are tubercular, 
or probably so, in nature. The general principles of diagnosis 
already outlined must be applied. Lepra will be dealt with below. 

Lupus resembles late syphilis. In the latter there are no lupus 
nodules. There is more destruction, and when ulcers form their 
margins are punched out, and the grouping of the lesions is renif orm 



TUBERCULOSIS AND LEPEA 285 

or f anlike. Lupus begins early in life, and the Wassermann reaction 
is absent. When syphilis attacks the nose it involves the bony archi- 
tecture, which causes sinking of the bridge, the tip remaining. Thus 
the well known picture of the saddle nose is created. 

Blastomycosis and sporotrichosis are more purulent or ulcera- 
tive. The lesions are shorter lived and the respective organisms 
are present. 

Lupus erythematosus is scalier, atrophic, and can be confused 
only with the rarer lupus vulgaris erythematodes which has the 
histological structure of tuberculosis. 

Sarcoid is more superficial, or deeper (see below), lacks the 
nodules, but often has tuberculous structure, and in that variety 
known as miliary lupoid of Boeck, Boeck has found tubercle bacilli. 
Erythema induratum, which closely resembles sarcoid, restricts itself 
almost entirely to the calf in young women. Papulo-necrotic tuber- 
culides resemble either lupus disseminatus or miliaris, but no lupus 
nodules are present. 

Etiology. Lupus vulgaris is caused by the bacillus of human 
tuberculosis. It may be the starting point of, or a complication of 
general tuberculosis, and its dissemination is either lymphatic or 
hematic. Measles appears to predispose to it. The disease is largely 
continental. In recent years, however, it is becoming common in 
the United States, particularly along the Eastern seaboard, at the 
great landing points of immigrants. 

Prognosis. Uncomplicated the prognosis of lupus vulgaris is 
good as far as life and health are concerned. Cosmetically the out- 
look never is encouraging, even though with suitable therapy the 
lesions may be caused to disappear, for unsightly scars remain. In 
necrotic forms, such as those destroying the nose, the outlines of 
the mouth, eyelids, etc., the disfigurement is horrible. In compli- 
cated forms the prognosis becomes that of the complicating dis- 
ease. 

Treatment. The general treatment corresponds with that of any 
other forms of tuberculosis. The best local treatment is with the 
Finsen light, but massive doses of X-rays and radium are also 
useful. Carbon dioxide snow is good only in small patches. But 
in these, wide excision is better. Curettage is dangerous, as it 
opens the lymphatics and promotes dissemination. Destruction with 
the actual cautery is excellent. The use of pastes such as pyrogallic 
acid, resorcin, etc., is fairly successful at times. Tuberculin injec- 
tions are useless. The best cosmetic results by far are those obtained 



2S6 DEKMATOLOGY 

by Fin son therapy. Lupus of the mucosa is best treated by the 
actual cautery or radium. Tuberculin is utterly useless. 

TUBERCULOSIS VERRUCOSA CUTIS 

Synonyms. Lupus sclerosus, Lupus verrucosus, Verruca necro- 
genica, Tuberculum Anatomicum, Dessection tubercle; German, 
Leichentuberkel. 

Definition. Tuberculosis verucosa cutis is a verrucous tuber- 
cular lesion of the skin due to local inoculation with the tubercle 
bacillus. 

Symptoms. The disease begins upon a previous abrasion as a 
papule, pustule or vesicle with an infiltrated reddish areola. The 
lesion spreads, forming indurated, horny excrescences which crust 
and become pigmented. It may remain small for months or years, 
or gradually enlarge, suppurate, or become secondarily infected. 

At times the disease becomes relatively extensive, always retaining 
the same features as those already described. The advancing mar- 
gin of the lesion is steep, the surface warty, and the color varied. It 
may be yellow, purple, brown or black, and present horny plugs as 
described. Small abscesses are often beyond the advancing ery- 
thematous zone, but never in it, as is the case in blastomycosis. 
Superficial erosions or ulcers may arise. The hands are chiefly in- 
volved, but other parts of the body may be. The disease may last 
for months or years, and although complications are rare, occasionally 
systemic involvement occurs. 

Varieties. There are two rare varieties. One is fibromatosis 
tuberculosa cutis in which a sclerotic process develops amongst the 
features described. This is found on the lips, nose, cheeks, anus and 
vulva. The other is elephantiasis tuberculosis cutis, and represents 
tuberculosis verrucosa cutis plus elephantiasis due to blocking of the 
lymphatics. 

Differential Diagnosis. Blastomycosis closely resembles tuber- 
culosis verrucosa cutis as to site and appearance. The discovery of 
the blastomycetes in the one, and tubercle bacilli, which are easy to 
find, in the other, completes the differential diagnosis. The periph- 
eral abscesses are present in the red margin of blastomycosis and 
beyond it in tuberculosis. Other conditions resembling tuberculosis 
verrucosa are lupus vulgaris, syphilis, sporotrichosis, etc. The dif- 
ferentiation follows along the lines indicated in lupus. 

Etiology. The cause is the tubercle bacillus, locally inoculated. 



TTTBEKCULOSIS AND LEPKA 287 

Vocation has a distinct bearing on the matter, as physicians, an- 
atomists, butchers, and undertakers are most frequently affected. 
On the other hand, miners and people going unshod are often in- 
fected, probably through the accidental introduction of tubercle 
bacilli into a preexisting skin injury. 

Treatment. The therapy is identical with that of lupus. 
Small lesions, however, may be successfully and easily excised. 

Prognosis. Save for the rare instances in which systemic 
tuberculosis develops, the prognosis is good. The cosmetic defects 
resulting are unimportant, as the disease involves the hands and feet 
chiefly. In the sclerotic type affecting the vicinity of the ends of 
the alimentary tract, and in the elephantiastic type the prognosis is 
poor, particularly from the cosmetic standpoint. 

SCROFULODERMA 

Synonyms. Tubercular tumors, Tuberculosis Fungosa, Tuber- 
culosis Colliquativa (Gummosa) Cutanea et Subcutanea; Scrofula, 
King's Evil, Cold Abscess of the Skin; French, Gomme Scrofulo- 
Tuberculeuse ; German, Kalte Haut und Unterhaut Ahzesse. 

Definition. Scrofuloderma is a colliquative tuberculosis of the 
skin and subcutaneous tissue usually causing necrotic, perforating, 
circumscribed nodules which arise by a direct extension from tuber- 
culosis of the deeper structures, but occasionally apparently within 
the skin itself. 

Symptoms. The skin becomes swollen, red or purple, and in- 
tumescent. After a prolonged period of development, an abscess 
forms which slowly, en masse, points and perforates. An ulcer 
is formed which lies deep in the infiltration from which it develops. 
The margins are inverted, undermined, and collapsed, the floor 
covered by unwholesome granulations secreting a thin watery sub- 
stance. Such lesions may be sparse or numerous. They are usually 
found in connection with an underlying tuberculous process, as tuber- 
cular adenitis of the neck, tubercular osteomyelitis of the jaw, ear, 
tear duct, long bones, or tubercular fistulae of the rectum, tubercular 
orchitis or vulvitis. In healing they leave either depressed pig- 
mented or irregularly linear or more rarely oval or circular scars. 

At times they seem to arise independently as irregularly dis- 
tributed lesions varying greatly in size. This form, rare as it is, is 
commonest in children, but may be present at any age, and the 
lesions are often mixed with papulonecrotic tuberculides. At times 



288 DERMATOLOGY 

scrofuloderma may arise from true lupus. Other form3 arise, as 
nodular lesions along an infected lymphatic (tubercular lymphan- 
gitis), and involve the skin subsequently. Affected patients usually 
have the symptoms of general tuberculosis; sweats, fevers, asthenia, 
amyloid disease, etc. 

Course. The cutaneous lesions are highly indolent, persisting 
with the underlying cause. 

Varieties. The only notable variants from the common picture 
are the disseminated tubercular tumors and localized tubercular 
tumors of which tuberculosis fungosa cutis, lupus tumidus, and 
frombesiformis, are rare and unimportant examples. 

Differential Diagnosis. Syphilis and other conditions must be 
excluded as in lupus. Lupus itself is excluded by the absence of 
nodules. The distinction is academic. The diagnosis is generally 
easy because of the underlying cause. The lymphangitic forms 
closely resemble sporotrichosis and blastomycosis, the differentiation 
depending upon a determination of the organisms. Scrofulous tissue 
is usually rich in tubercle bacilli which can be determined micro- 
scopically or by animal inoculation. 

Etiology. The disease is due to direct involvement of the skin 
from deeper organic tuberculosis, chiefly of the glands and bones, but 
at times from tubercular lymph vessels. 

Treatment. Surgical removal of the underlying cause cures 
some cases. General medical treatment common to all forms of 
tuberculosis is indicated; and local therapy corresponds to that of 
lupus. 

Prognosis. If the underlying cause is traceable the prognosis 
is good, otherwise the prognosis becomes that of the general basic 
condition. In lymphangitic forms the outlook is poor. 

Tuberculosis ulcerosa miliaria is rare. Small jagged ulcers follow tiny- 
brownish scaling papules. They rarely exceed a diameter of one inch and 
the ulcers are shallow. The usual site is near the body orifices, hence the 
term tuberculosis orificialis. It is usually secondary to intestinal or pul- 
monary tuberculosis. 

Nonmiliary Tubercular Ulcers. This is a vague clinical condition. 
Isolated tuberculosis ulcers, now resembling lupus, now scrofula, now tu- 
berculosis verrucosa cutis arise. Any site may be involved. The ulcers are 
large, and somewhat deep, arise spontaneously, or after injury, and have an 
inconsistent clinical aspect. This class need be mentioned only to be dis- 
missed with a word. 

Tuberculosis miliaris propria, or disseminated miliary tuberculosis. The 



TUBEKCULOSIS AND LEPEA 289 

disease represents the cutaneous phase of acute general miliary tuberculosis, 
or a hematogenously disseminated tuberculosis of the skin from a visceral 
focus. 

LINGUAL TUBERCULOSIS 

The forms of lingual tuberculosis are numerous and deserve special 
mention. Thus this somewhat artificial separation is justified by 
convenience. 

Lupus vulgaris attacks the tongue as a series of nodules. The 
ulcerative forms may be miliary, the tongue being covered with 
lesions suggesting tuberculosis orificialis, or there are numerous 
larger ulcers. These are relatively shallow, have finely jagged edges 
and cover the tip and dorsum. They are painful and when deeply 
infiltrated must be distinguished from gummata and epitheliomata, 
a matter often requiring bacteriological and histological study. 

Clinically, syphilis may be excluded by the fact that leucoplacia 
is usually present in the latter, or interstitial glossitis, and because 
gummata of the tongue ulcerate less easily and are more numerous. 
Epithelioma is usually single, more painful, and prone to arise at or 
near the side of the tongue at a site opposite the molars. Epithe- 
lioma, however, often springs from a leucoplacia. 

TUBERCULIDES 

Earlier passages in this chapter dealt with the limitations of the 
term tuberculides* This matter deserves elaboration. The number 
of clinically dissimilar conditions now included in this group is 
large, and it is often difficult to conceive of any inter-relationship 
among them. A relationship with tuberculosis is implied. Thus, 
tuberculides have been considered as due either to attenuated or 
dead bacilli (minute granulomas), bacillary toxins (allergic; 
erythemas or minute granulomas). Evidence favoring the assump- 
tion that these lesions are tubercular may be summed up as follows. 
They are often associated with some other form of tuberculosis, 
including tuberculosis of the skin. Bacilli have been demonstrated 
in the lesions microscopically and by animal inoculations. The 
lesions are often tubercular in minute structure. In a large num- 
ber of instances these facts are undemonstrable in lesions clinically 
tuberculides. These are the bare outlines of the problem. The con- 
clusion is inevitable that a group of skin lesions exists, the relation- 
ship of which to tuberculosis is often apparent, often presumptive, 
often impossible to prove. Because of their clinical similarity it 



290 DERMATOLOGY 

is at present still justifiable to group them together, with the men- 
tal reservation that when their bacterial origin is established they 
cease to be tuberculides and become skin tuberculosis, and when 
they are shown to be alien to tuberculosis they must obviously no 
longer be considered tuberculides. To one acquainted with the 
doctrine of skin reactions this is neither new nor astonishing. 

LICHEE SCROFULOSORUM 

Synonym. Lichen scrofulosus. 

Definition. Lichen scrofulosorum is a benign disseminated form 
of tuberculosis characterized by the presence of grouped minute lich- 
enoid papules, chiefly on the trunk of children and young adults. 

Symptoms. Minute yellow, flesh-colored, or dirty gray, papules 
appear, and are isolated, grouped in discoid patches or in circular or 
crescentric figures. Each papule is covered by a tiny scale. There 
are no subjective symptoms, and often general evidences of tuber- 
culosis are present. The sites of election are the sides of the torso 
from the axillae to the iliac crests, but often the buttocks, back, belly 
and chest are involved, and rarely the extremities. 

Course. The disease may last for weeks or months. It vanishes 
spontaneously but sometimes recurs. 

Diagnosis. Lichen planus, lichen acuminatus, papular derma- 
titis and lichen syphiliticus are to be differentiated from lichen 
scrofulosorum. All of the above conditions usually occur at a later 
age than lichen scrofulosorum, and the first three itch. In lichen 
planus there is involvement of the mucosa and in lichen syphiliticus 
there are other classical evidences of secondary syphilis. 

Etiology. Jacobi, Haushalter, and Pellizari demonstrated the 
tubercle bacillus in lichen scrofulosorum. This transferred the con- 
dition to the group of true tuberculosis wherein it would have to 
be considered a benign miliary type. Its structure is tubercular. 
Infancy, childhood, and adolescence are the periods favoring the 
disease. It is commonest in the first of these periods. In some 
forms no evidence of tubercular origin can be found. 

Treatment. The general tuberculosis underlying the disease 
furnishes the therapeutic indications. 

Prognosis. In so far as the rash is concerned the prognosis is 
good. 

PAPULONECROTIC TUBERCULIDES (eIG. 63) 

Synonyms. Acnitis, Folliclis (Barthelemy), Lupus Erythemato- 



TUBERCULOSIS AND LEPRA 291 

sus Disseminatus (Boeck), Acne Telangiectatica (Kaposi), Paratu- 
berculosis (Johnston), Toxituberculides (Hallopeau), etc. 

Definition. Papulonecrotic tuberculides are papules on the face 
and extremities. They are hard, infiltrated, come in crops and dis- 
appear spontaneously leaving pitted scars. The condition is often 
associated with general or skin tuberculosis of another type. 

Symptoms. At first brown, red or purplish papules appear at 
the sites affected. These are indolent, and gradually a crust 
develops centrally, the removal of which discovers a necrosis or 
ulcer. Healing is gradual and a central pitted scar remains. Slight 
itching or burning may be noted but usually the patient complains 
of nothing at all. Other evidences of systemic tuberculosis may be 
present, or the lesions may exist coincident ally with other forms 
of skin tuberculosis, notably lupus vulgaris or scrofuloderma, or 
with other tuberculides, chiefly erythema induratum or lupus 
erythematosus. 

The lesions tend to come in crops over periods of years and may 
be numerous. They may be sparse indeed, particularly in babies, 
in whom they often represent the first evidence of a systemic infec- 
tion terminating with the picture of pulmonary, meningeal, or 
some other form of visceral bone or gland tuberculosis. 

Course. The course may be inferred from the foregoing. 

Varieties. Acnitis is that form which involves the face, espe- 
cially the cheeks, brow, lips and chin. The lesions may reach the 
size of a pea and are hard and shotty. They are associated com- 
monly with the next form to be described. 

Folliclis. The appearance of folliclis is identical with that 
of acnitis, and except for localization no difference exists between 
the two. The hands, forearms, feet and legs are affected, the body 
being rarely involved. It is in acnitis and folliclis that crops are 
commonest, the course of each crop approximating four to six 
weeks. At times the necrotic centers are purulent and this is 
especially the case in a rare subvariety seen chiefly in London and 
called acrodermatitis pustulosa hiemalis, the name describing the 
salient attribute of the condition. This form favors the knuckles. 
Acne scrofulosorum is also a rare subvariety involving the outer 
aspects of the limbs, the lower extremities being more frequently 
involved. A shallow pitted scar remains. The sacral region may 
be involved. This form is closely related to acne cachecticorum, 
the lesions of which favor the trunk. In general it may be stated 



292 DEKMATOLOGY 

that the differences among these types are artificial rather than 
actual. 

Acne Necrotic a is a condition hitherto not classed among the 
tuberculides. Its best known synonyms are acne varioliformis and 
granuloma necroticum. The lesions resemble those of acnitis and 
are similarly situated. They differ, however, in being follicular. 
Their association with tuberculides has been mentioned by Scham- 
berg. 

Differential Diagnosis. Save for syphilis nothing can be con- 
fused with tuberculides. The differentiation can be made by 
clinical and serological study. 

Etiology. Often some form of systemic or cutaneous tubercu- 
losis is ascertainable. This, together with the facts that histologi- 
cally tuberculosis is often suggested, that tuberculin reactions both 
general and local may frequently be elicited and that at times the 
tubercle bacillus has been demonstrated microscopically or by 
animal inoculation, indicate clearly that at least a substantial pro- 
portion of the cases are tubercular. On the other hand, in many 
cases these criteria fail, and in these the causation is unknown. 

Treatment. The general management of tuberculosis is to be 
pursued where indicated. The best local treatment is the use of 
weak ammoniated mercury salve. Tuberculin is useless. As a 
matter of fact the vagaries of the disease are its most striking 
feature, and measures that appear efficacious at one time may be 
fruitless at another in the same individual. 

Prognosis. The prognosis as to the lesions is good, as they 
tend to disappear spontaneously. If they be associated with tuber- 
culosis the prognosis becomes one with that of the major condition. 

LUPUS ERYTHEMATOSUS (FIGS. 64 AND 65) 

Synonyms. Lupus Erythematodes (Cazenave) ; Erythema Cen- 
trifugum (Biett), Ulerythema Centrifugum (TJnna), Seborrhoea 
Congestiva (Hebra). 

Definition. Lupus erythematosus, in its usual form, is a com- 
mon inflammatory disease, the lesions of which develop gradually 
as symmetrical red or purple scaling patches, and involute slowly 
leaving a delicate atrophic scar. Although the disease is chronic 
as to its entire course, the lesions may sometimes develop and re- 
solve quickly so that the individual exacerbations and remissions 
may in time be chronic or acute. In addition there are acute 



TUBERCULOSIS AND LEPEA 293 

varieties which terminate quickly and fatally, or which, developing 
suddenly, become chronic. 

Symptoms. The condition starts at adolescence or in early 
adult life with patches on the head, hands, or rarely elsewhere on the 
body. The portions of the head most involved are the nose, cheeks, 
forehead, ears, scalp, vermilion border of the lips, and the mucous 
covering of the tongue and cheeks. 

At first the lesions are pale pink, small, slightly elevated macules 
which may grow gradually over a period of weeks, months or years, 
reaching great proportions at times, but usually ranging between 
one-eighth of an inch and two inches in diameter. The lesions (Fig. 
64) are circular or oval and sharply circumscribed, with a slightly 
elevated border, or one more markedly raised and infiltrated. The 
entire patch is sometimes as high as the margin, or sunken ; and often 
there is central involution surrounded by a more or less broad 
active ring. Such a lesion may remain as described for varying 
periods even up to years, or gradually grow, or remain stationary, 
grow suddenly, and again become stationary. The advancing or 
stationary lesions are a vivid red, but often a distinct brown or 
purple hue is noted which is accentuated in low temperature. 

The surface of the lesions is covered with adherent greasy scales, 
which are white, yellow or gray, from the lower surfaces of which, 
when they are lifted off, project minute horny plugs. These plugs 
are scaly casts of patulous pilosebaceous follicles. Thus, when de- 
nuded of its scales, the lesion is pitted because of the dilated follic- 
ular openings. 

The lesions may be single but it is more characteristic for them to 
be multiple and symmetrical. Their circular or oval outline, due 
to coalescence, becomes festooned or irregular. At times nearly the 
entire face is masked by merging of lesions (Fig. 65). A figure 
frequently formed is that of an open butterfly when lesions cov- 
ering the bridge of the nose and adjacent cheeks, unite into one 
plaque. 

After involution an atrophic pliable, delicate, white and super- 
ficial scar remains. Upon the ears such scars destroy the soft parts 
of the helix down to the cartilage, giving a picture identical with 
that of chilblain scars. The active lesions themselves, particularly 
on the nose, ears and fingers also suggest the active stage of pernio. 
Eecurrence in the scars is possible. 

The process is destructive. Thus under the microscope the skin 



294 DERMATOLOGY 

organs axe absent, and when atrophy has occurred the entire follic- 
ular structure and elastic fibers have vanished. Hence the scar is 
pearly white or pink, pliable except in the scalp where the flesh 
cannot be pinched up, and it puckers easily and is moveable. When 
scars have formed on the scalp there are local areas of baldness, in 
contour not unlike those seen in alopecia areata. 

Lupus erythematosus of the lips causes edematous, red patches 
with pearl gray slightly raised margins. Healing produces atrophy 
with a peculiar glassy surface. Similar lesions are noted when the 
tongue is involved. Active lupus erythematosus of the scalp often 
is elevated and the patch scales markedly but is even more markedly 
the site of hyperkeratotic plugs. Thus the surface suggests that of 
a strawberry to the touch and eye, save that it is never so vividly 
red. 

Course. The course of the disease is long, that of the lesions or 
crops of lesions varies as indicated in the definition. 

Varieties. Lupus erythematosus discoides (Fig. 64) may be lo- 
calized or disseminated (Fig. 65), but the true disseminated type con- 
sisting of typical lesions, is not lupus erythematosus discoides, but 
is better known as lupus erythematosus exanthematicus and will be 
described below. At times, however, the true exanthematous form 
rises after or leads to the discoid type. 

Differential Diagnosis. To make this clear it will be necessary 
to subdivide the manifestations of the disease arbitrarily and to 
deal with the disease in its individual various manifestations. The 
active lesions resemble seborrhoea, psoriasis, rosacea, lupus vulgaris, 
sarcoid, lepra and chilblains. The scars on the glabrous areas 
resemble those of superficial macular atrophies and morphoea. The 
scars on hairy areas suggest alopecia areata, pseudopelade and favus. 
The mucous lesions suggest lichen planus, syphilitic leucoplacia and 
superficial basal celled epithelioma prior to ulceration. 

Seborrhoea itches, is yellowish, less infiltrated, more disseminated, 
more localized to the nasolabial and post-auricular folds. The 
scales are less adherent and have no inferior plugs. The disease 
responds more readily to therapy than lupus erythematosus, and 
there is no atrophy. 

Psoriasis is covered with nacreous white scales, is more typically 
localized, and is distinguished by these differences along the lines 
indicated in seborrhoea. Bleeding upon excoriation is another im- 
portant diagnostic feature of psoriasis. 

Rosacea resembles the butterfly wing type of lupus erythematosus, 



TUBERCULOSIS AND LEPRA 295 

but it is not elevated, scales more lightly and is greasier. The flush 
increases in warmth rather than in lower temperatures, and it is 
associated with pustular folliculitis. 

Lupus vulgaris differs from lupus erythematosus in the greater 
irregularity and tumefaction of the lesions and in the presence of 
the yellow lupus nodules revealed by glass pressure. Sometimes 
the diseases coexist. Similar yellow nodules are seen in lupus 
erythematosus. They are clumps of degenerated elastic tissue, but 
the nodules of lupus vulgaris yield easily to a blunt probe, while those 
of lupus erythematosus do not. Microscopically lupus vulgaris has 
the structure of tuberculosis. 

At this point it may be mentioned that the microscopic study of 
lesions helps in differentiation from sarcoid and lepra also. In 
sarcoid there is a granulomatous structure suggesting tuberculosis. 
In lepra the lepra cells and Hansen bacilli are found except in the 
maculo anesthetic forms. Lupus erythematosus is a chronic inflam- 
mation leading to destruction of elastic and connective tissue and 
shows nothing suggestive of a tubercle or leproma. Maculo anes- 
thetic leprides are insensible. Chilblains are clinically like lupus 
erythematosus both when active and in their destructive propen- 
sities, differing only in that the latter are less marked and more 
infrequent, and that the condition is confined to cold seasons. 

The lupus erythematosus scar is like that of macular atrophy, 
but the early stages of the two diseases differ. A puffy white, red, 
or faintly violet lesion precedes the scar of macular atrophy. 
Without a knowledge of the early forms the two could hardly be 
distinguished. The same applies to morphoea save that the scars 
are firmer. 

Alopecia areata resembles the scar of lupus erythematosus only 
in outline. The alopecia patch is not a scar. The follicles are 
present, the hairs rapidly grow again, the skin is pliable. 

Pseudopalade cannot be differentiated from the cicatrix of lupus 
erythematosus except in so far as other evidence of either disease 
exists. 

Favus is practically restricted to Russian Jews, the scar is irreg- 
ular and it binds down. 

Lichen planus of the mucosa consists of minute polygonal papules 
and, as a rule, typical skin lesions indicative of either disease are 
present. 

Leucoplacia is dead white, irregular, and serological and other 
clinical evidences of syphilis are found. 



296 DERMATOLOGY 

Superficial epithelioma can usually be ruled out easily as the 
lupus margin is less rolled. A microscopic examination would 
clear up the puzzling cases. 

Etiology. The etiology of lupus erythematosus is not definitely 
known. Darier considers the disease an atrophying erythematous 
tuberculosis. Microscopically and bacteriologically there is nothing 
whatever to justify this point of view. The disease, however, is 
frequently associated with systemic and other forms of skin tuber- 
culosis, as are other tuberculides. Thus the non-tubercular types 
may be assumed to be due to some focal infection or metabolic dis- 
turbance. 

Therapy. Treatment is general and local. By virtue of our 
ignorance of the cause of the disease there is no rational general 
treatment other than those vague measures employed in managing 
any serious disease. Local treatment consists of the use of acids 
or certain actinic rays. Of the former, trichloracetic acid is the 
best. It is applied once a week, each time until the skin is blanched, 
which occurs in a fraction of a minute. The best ray therapy is 
furnished by the use of the Kromayer light, applied unfiltered for 
three or four minutes to each patch, weekly. X-rays are contra- 
indicated, but radium has been found of value. Some cases respond 
well to one form of treatment, others to another, and even different 
lesions, in the same individual, vary. The internal administra- 
tion of quinine coupled with tincture of iodine locally has had wide 
vogue, particularly in Germany. In the very acute forms soothing 
lotions of the calamine and zinc type are to be employed until the 
skin is ready for the revulsives mentioned. Destructive local treat- 
ment is the only logical form to employ. A small proportion of 
cases in intractable. 

Prognosis. This is usually bad as to prevention of recurrences 
and good as to curing the attack. Sometimes the attacks, however, 
will not disappear either spontaneously or with all our arts. As a 
rule discoid lupus erythematosus does not menace general health. 

LUPUS ERYTHEMATOSUS DISSEMINATUS 

This rare form of disease, better called lupus erythematosus exan- 
thematicus, arises spontaneously and acutely and may run an acute, 
subacute, or chronic course. At times its starting point is in lupus 
erythematosus discoides, more rarely it terminates in this picture. 
Usually it looks nothing at all like lupus erythematosus but closely 
resembles erythema multiforme. Its systemic features, however, are 



TUBERCULOSIS AND LEPRA 297 

severer, it often terminates fatally, there are fever, abdominal cramps, 
pains in the bones and joints, and even delirium and coma. Sub- 
acute forms are characterized by a milder course and frequent oc- 
currences. 

A very serious form of the condition is Kaposi's erysipelas 
perstans faciei, which starts with facial lesions resembling the 
discoid or disseminated sort. These coalesce, the face becoming 
swollen and dusky. Severe systemic symptoms develop, and lesions 
on the body suggesting either lupus erythematosus discoides or 
disseminatus are found, or other evidences of systemic or skin tuber- 
culosis. The patients usually die after a few weeks or months. 
Albuminuria is common and nephritis frequent. The therapy is 
symptomatic, the etiology obscure and the prognosis bad. 

Lupus pernio, also known as chilblain lupus, has been alluded to 
in connection with lupus vulgaris. Many authors associate it with 
the latter, others with lupus erythematosus. It is a papular, 
cyanotic disease of the fingers, toes, nose, ears, etc., and it is scaly 
and leads to atrophies and mutilating scars. Thus it closely resem- 
bles lupus erythematosus, but microscopically it often is tubercular 
in structure. 

Lupus erythematosus telangiectaticus is rare and resembles the 
ordinary forms of the disease — but is more vascular and less scal- 
ing. It causes atrophy and its vascularity takes the form of telan- 
giectatic vessels lying in the erythematous lesion. 

SAECOID 

Synonym, Multiple Benign Sarcoid (Boeck), Benign Miliary 
lupoid (Boeck), Nodular Hypodermic Tuberculide (Darier). 

Definition. A generation ago this group of cutaneous lesions 
was expansive. It included mycosis fungoides, hemorrhagic sar- 
coma of Kaposi, xanthoma tuberosum and leucemia of the skin. 
The reason for this unwarranted association of entirely unrelated 
entities lay in the clinical fact that although they resembled sar- 
coma they were not sarcomas. Thus the term sarcoid had been 
coined. When Boeck first described the condition named for him 
he included it among the sarcoids because of its clinical resemblance 
to the group mentioned. One by one each of the diseases in question 
has been otherwise classified, and the list has shortened till one 
survivor remains, the multiple benign sarcoid, for which Boeck 
himself has suggested as a better designation miliary lupoid. In 
spite of this the term sarcoid persists. Sarcoids are chronic 



298 DEKMATOLOGY 

granulomatous lesions remotely suggesting sarcoma and somewhat 
suggesting atypical lupus erythematosus in their clinical appear- 
ance. They closely simulate cutaneous tuberculosis histologically. 

Symptpms. Sarcoids may be superficial or deep, in other words 
dermic or hypodermic. The first in turn forms small nodules, large 
nodules or plaques. The dermic variety bears Boeek's name, the 
hypodermic Darier's. 

Boeck's sarcoid favors the face and shoulders and upper extremi- 
ties but may be diffusely disseminated. The lesions, whether small, 
large, or in plaques, start as red, edematous or infiltrated spots 
which turn purplish or brownish, are elevated as much as a quarter 
of an inch, and bum or itch. They grow purple and telangiectatic 
centrally. The margin turns brown or yellow and scales, and as 
involution sets in they fade leaving a brownish discoloration and a 
slight atrophy. They never break down. 

The small lesions are as large as a pinhead or hemp seed. The 
large ones may be an inch or more in diameter and higher than the 
smaller lesions. The diffusely infiltrated lesions may reach the size 
of a hand. Of course all start as small nodules. Diascopic exam- 
ination shows that the elemental feature is a grayish yellow minute 
point suggesting a remote similarity to the lupus nodule. Hence the 
term miliary lupoid. The gross appearances of the nodules, then, is 
the sum of these numerous miliary structures set within an engorged 
or telangiectatic background. The elevation is due to infiltration 
and edema. The scarring is the result of connective tissue destruc- 
tion. Patients presenting the picture here described usually seem 
in good health. At times the glands are enlarged. 

The hypodermic form, or Darier's type, also known as Darier- 
Roussy's form, is a granuloma of the subcutaneous tissue. This 
forms a nodular lesion about the size of a hazel nut or a walnut. 
The tumors are globular or oval, the skin over them reacting as in 
Boeck's form, and they are freely moveable below. Coalescence 
causes them to form irregular deep plaques, some even eight to ten 
inches in diameter. The overlying skin, adherent to the infiltration, 
resembles orange peel in character, when pinched. The color is 
purple, slate or red. This form favors the trunk. 

Course. The course of the disease is slow, the lesions requiring 
months or years to unfold and involute. Therapy curtails the 
disease. 

Varieties. These have been mentioned in the symptomatology. 

Differential Diagnosis. Sarcoma, mycosis, lupus erythematosus, 



TUBEKCULOSIS AND LEPEA 299 

lupus vulgaris, erythema induratum, erythema nodosum, and 
periosteo-cutaneous gumma must be excluded. Sarcoma is excluded 
by histological study. Mycotic and leucemic infiltrations usually 
itch intensely, and here again microscopic study is often necessary. 
Lupus erythematosus when edematous is not very scaly, and lupus 
erythematosus telangieetaticus so closely resembles sarcoid that no 
clinical differentiation is possible. Only the histological structure, 
which is that of tuberculosis, will clear up the diagnosis. Lupus 
vulgaris contains yellow nodules, as opposed to the miliary spots of 
sarcoid. It is a process destructive through necrosis rather than 
through atrophy. Erythema induratum is so like Darier's form as 
to be considered by many identical with it. This will be discussed 
below. Erythema nodosum is acute and attended by mild or severe 
systemic symptoms chiefly rheumatoid in type. The lesions are both 
painful and tender and have the appearance of contusions. All of 
these features are absent in sarcoid. Syphilitic periostitis of the 
tibia secondarily involving the skin is painful and tender. The 
lesions resemble those of the deep sarcoids. Other manifestations 
of lues, however, are present and the Wassermann reaction is elicited. 

Etiology. Boeck found tubercle bacilli in one of his cases and 
Darier and Roussy in one of theirs. The structure of the lesions 
is like that of tuberculosis. Women are afflicted more than men. 

Treatment. Arsenic is almost a specific. 

Prognosis. This is generally good. 

ERYTHEMA INDURATUM (FIG. 66) 

Synonyms. Erythema Indurativum; Erench Erytheme Indure 
des Scrofuleux (Bazin). 

Definition. Erythema induratum is a granuloma attacking by 
preference the calves (Fig. 66) of young individuals, chiefly females. 
It is prone to break down and is often associated with papulo-necrotic 
tuberculides. 

Symptoms. The disease begins with pain at the sites mentioned 
and at the age reported, but the lesions may occur elsewhere and in 
later years. The nodules are hard and resemble the hypodermic 
sarcoids, but often break down into punched out or irregular ulcers. 
The lesions resolve spontaneously and tend to recur. 

Course. The course of the lesions themselves requires months 
to be completed and they leave pigmented scars suggesting those of 
syphilis. The entire condition is characterized by recurrences, the 
general health not suffering materially. 



300 DEKMATOLOGY 

Differential Diagnosis. The disease is identical with Darier's 
sarcoids save that it tends to limit itself to the calf and is necrotic. 
To enumerate the conditions from which it is to be differentiated 
and the method of accomplishing the differentiation would be to 
repeat the corresponding passage in connection with Darier's 
sarcoids. 

Etiology. Successful animal inoculations indicate that the 
tubercle bacillus is probably the cause of this disease. Women are 
afflicted more than men. 

Treatment. Antiseptics locally, calomel injections as in syphilis, 
and tuberculin injections, are useful. The attacks tend to be self 
limited. 

Prognosis. This is good. 

Presumptive tuberculides, pernios, chilblains, frost bites, are in some of 
their forms possibly tuberculides. They are related to lupus vulgaris or 
lupus erythematosus. 

Pityariasis Rubra (Hebra-Jadassohn) has been described 
(Chapter XII). It is a generalized exfoliative erythroderma, and 
because in so many instances systemic tuberculosis has been dis- 
covered at autopsy it is believed that at least a considerable propor- 
tion of the cases are due to tuberculosis. In one instance Brus- 
gaard found tubercle bacilli in the skin. 

Angiokeratoma of Mibelli is a rare disease usually found in 
adolescent girls. The toes and fingers are covered with pink, minute 
macules, gradually becoming cyanotic, which are hyperkeratotic, 
smooth or rough. Under the diascope a persistent central angioma 
is seen. The lesions have been found accompanying other tubercu- 
lides, but the relation to tuberculosis is not definitely established. 
The condition, or a similar one, is often seen on the scrotum in men 
obviously not tubercular. 

A follicular eczema resembling Morris's has been considered by 
some to be related to tuberculosis. 

DISEASES SOMETIMES HISTOLOGICALLY RESEMBLING TUBERCULOSIS 

Lichen nitidus has been already referred to (Chapter XIII). 

Granuloma annulare (Chapter VIII) or ringed eruption, is ex- 
tremely rare. It is found upon the back of the hands, finger3, 
wrists, neck, elbows, ankles and buttocks. The lesions consist of 
rings formed of an elevated margin one eighth of an inch broad and 
about one sixteenth of an inch high. The rings may be complete, 



TUBERCULOSIS AND LEPRA 301 

or only in segments, and the outer aspect is deep and sharp, the inner 
gradual and merging into an enclosure of normal or slightly atrophic 
skin. Within the enclosure are papules strongly suggesting those of 
lichen planus. The color of the rings and papules is flesh toned, 
pink or vivid red. Single lesions or numerous rings are found. 
The etiology is unknown but sometimes the patients give a tuber- 
culin reaction. At times the minute anatomy is suggestive of 
tuberculosis. . The prognosis is good and the best treatment a single 
Koentgen exposure to three or four Holzknecht units. 

LEPRA. 

Synonyms. Leprosy, Morbus Biblicus, Elephantiasis Greacorum, 
Lepra Arabium, Leontiansis. Norwegian, Spedlasked; German, 
Aussatz; French, Lepre, Ladrerie. 

Definition. Lepra is a chronic infectious disease caused by the 
bacillus leprosus, or Hansen bacillus. It runs a course of years, in 
which there are eruptive and general phases. 

Symptoms. During the incubation period, the length of which 
is unknown, there may be no symptoms or there may be weakness, 
anemia, desire to sleep, arthralgia, neuralgia, diarrhoea, headache 
and vertigo. As a rule the fever is slight but there may be hyper- 
pyrexia with morning remissions suggesting sepsis. An obstinate 
coryza with epistaxis, and local asphyxias of the extremities are not 
unusual. Thereupon the macular stage arises. A roseola appears 
upon the face, extensor surfaces of the extremities, and particularly 
upon the thighs and back. The macular leprides are erythematous 
resembling toxic eruptions that are red, bronzed, or yellow, or even 
rosaceous. In addition there are depigmented macules surrounded 
by hyperpigmentation, and often these are anesthetic, but sometimes 
hyperalgesic. These eruptions are composed of lesions irregular in 
size and shape, and the different types may be intermingled. 

At times bullae develop after the macular stage but more often 
it evolves directly into the nodular phase, giving the picture of tuber- 
ous, nodular or tubercular lepra. These lesions are distributed as 
the macules are, and may be small or large, dermic or hypodermic 
(as sarcoids), and impart to the face a characteristic appearance 
known as the leonine facies or leprous leontiasis. Modules involve 
the ears, forehead, eyebrows, sides of the nose and chin in symmet- 
rical, irregularly disposed rows that cause the brows to overhang, 
and the features to change in a manner suggesting a lion's face. The 
nose grows large and flat, the eyebrows and nails fall or at least 



302 DERMATOLOGY 

get lustreless, the hair grows sparse and the ear lobes are studded 
with nodules. 

The extremities are covered with the nodules which have a cop- 
pery or red color and are somewhat waxy. Often they are scaling 
and erythematous, and elephantiasis of the legs is frequently seen. 
The glands are enlarged. Rarer participants in the process are the 
larynx, conjunctiva, sclera, iris, and thoracic and abdominal viscera. 
Orchitis is not rare. Often the nasopharynx is the site of lepra 
nodules. 

The above description is that of nodular lepra. Another equally 
important picture is that of anesthetic, maculo-anesthetic, nervous 
or trophoneurotic lepra. It too may have a prodromal and macular 
stage. The peripheral nerves, however, become the site of lepromas. 
Thus, on palpation, they are found to be nodular and enlarged. 
Neuritis and trophic disturbances, neuralgia, anesthesia, analgesia, 
and a picture suggesting syringomyelia or Morvan's diseases is 
evolved. There are perforating ulcers and the like. 

Mixed forms are known and both types may lead to the picture 
of mutiliating lepra, with amputation of fingers, toes, or even larger 
portions of the members. Decubiti and bony rarefaction are not 
uncommon and the patient ends his existence emaciated, deformed, 
blind, paralyzed, dying of leprous cachexia, or an intercurrent in- 
fection. 

Course. This covers a period of years and is divided, as stated 
above, into a period of incubation, eruption, nerve involvement, or 
both, and finally death. 

Varieties. There are two varieties, as already stated — nodular 
and maculo-anesthetic or nervous. 

Diagnosis. When lepra is suspected the similarity to tubercu- 
losis and syphilis is so great that diagnosis often depends upon the 
microscope. The bacilli are easy to find both in smears from punc- 
tured skin lesions and from the nasal secretion. The anatomy of 
the lesions is fairly characteristic, what with the lepra cells and 
Hansen bacilli. Tubercle bacilli are harder to find in sections and 
when present are less numerous than those of lepra, and morphologi- 
cally a trifle different. The Wassermann reaction is present in 
nodular lepra so that this means of differentiating it from syphilis 
is vitiated. The tuberculin reaction is absent in lepra, but a leper 
may have had or may have tuberculosis, so that its absence is sig- 
nificant but its presence does not exclude lepra, 

Neither in tuberculosis nor syphilis are there sensory disturbances, 




Fig. 61. LUPUS VULGARIS 

At the tip of the nose and over the bridge are seen " lupus nodules." Else- 
where the lesions have run together into confluent elevated patches. There is 
scaling, but no pustulation or scarring, in this patient. The color is usually 
red or purple. Often the distribution of lupus vulgaris and lupus erythema- 
tosus is the same, but by regarding Fig. 57 the atrophy and lack of nodules in 
the latter will be noted. 




Fig. 62. LINGUAL TUBERCULOSIS 

The ulcers in lingual tuberculosis are irregular, have undermined edges, 
a red floor, and usually the bacilli are demonstrable in smears. 




PAPULONECROTIC TUBERCULIDES 

Small papules with necrotic centres and red zones, and 
residual scars characterize the disease. On the face the 
condition is called acnitis; elsewhere, folliclis. The dis- 
tinction is artificial. Often lesions are associated with 
those of lupus, lupus erythematosus, sarcoids, or erythema 
induratum. 




Fig. 64. LUPUS ERYTHEMATOSUS DISCOIDES 

Symmetrical red patches form, usually on the face. They are slightly 
raised, infiltrated, scaly, and lead to atrophy, as seen over the eyebrow 
and margin of the ears. At the latter site the atrophy has deformed the 
ear. 



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Fig. 65. LUPUS ERYTHEMATOSUS DISCOIDES DISSEMIXATUS 

In this disease, lesions occur over widely disseminated areas but are other- 
wise of the same nature as the simple discoid variety. In the acute dissemi- 
nated form, erythema multiforma is more closely simulated, and the disease 
is at times fatal. In acute erythematous facial lupus erysipelas may be mim- 
icked. 




Fig. 



ERYTHEMA INDURATUM OF BAZIN 



The site is typical. The lesions break down, as here shown, and 
closely resemble gummata or deep sarcoids. Women are rather more 
commonly affected thfin men. Sarcoids rarely break down, and in gum- 
mata the Wassermann reaction is likely to be present. 



TUBEKCULOSIS AND LEPRA 303 

but in syphilis of the central nervous system there may be trophic 
disturbances. Analysis of the cerebrospinal fluid would prevent 
confusion. 

The clinical differences between the lesions of lepra on one hand 
and tuberculosis and syphilis on the other would have to be worked 
out by inspection. This has been dealt with adequately in the pas- 
sages on tuberculosis. Lepra may simulate mycosis fungoides. 
The latter itches and is histologically different. 

Nerve lepra simulates syringomyelia as to atrophy of muscle, 
particularly the interossei, and as to the presence of perforating ulcers 
and other trophic disturbances. The lepra claw is quite distinctive, 
the proximal phalanges being flexed, the distal extended. The ulnar, 
great auricular, peroneal, tibial, and the branches of the brachial 
plexus are palpable and irregular. In syringomyelia the skin lesions 
are present only within the area of nerve involvement. In lepra they 
may be elsewhere. The tendon reflexes are absent in the former and 
increased in the latter. 

Etiology. The cause is the Hansen bacillus. Contributing 
causes are prolonged exposure, crowding and filth. In warm 
climates the bulk of the cases are of the nerve type. In cooler dis- 
tricts the reverse obtains. The exact mode of transmission is not 
yet known, but it is probable that an intermediate epizoon is the 
carrier. 

Treatment. Segregation for prophylaxis is the most important 
measure. Tonics, arsphenamin, nastin and many other drugs have 
been employed with discouraging results. Of all methods, to-day, as 
of old, the best is the use of chaulmoogra oil. This substance is 
given three times daily, after meals, in capsules containing fifty to 
eighty drops, the average being sixty. At the same time a fiftieth 
of a grain of strychnin is given. I was told that at the Louisiana 
State Home for lepers this therapy was considered the most sat- 
isfactory. 

Prognosis. Although, on the whole, the prospects of a cure are 
never brilliant, with the treatment outlined above, a certain number 
of cases are arrested, and others ameliorated. 



GROUP VII. GRANULOMATA 
CHAPTER XXVI 

NON-INFECTIOUS GRANULOMATA 

In designating the conditions to be described in this chapter as 
non-infectious granulomata something perhaps unjustifiable is 
assumed. The view has not entirely been abandoned that these 
conditions are infectious. There is no evidence supporting this 
attitude, and indeed, it must be confessed that granuloma fungoides 
in many respects conveys an impression of possible infectious origin. 
On the other hand nothing is known that substantiates this feeling. 
The granulomata perhaps resemble those of syphilis, tuberculosis 
and lepra. Dermatoses in the prefungoid stage of mycosis consti- 
tute a rough analogy to the macular syphilides and leprides. Yet 
reasoning by analogy is inconclusive. Certainly no real evidence 
of infection exists. No proof of transmission is recorded. ISTo in- 
fectious agent is known. Mycosis and leucemia resemble sarcoma 
even more than they do the infectious granulomata. The iodides 
and bromides (Chapter VII) also cause polymorphous manifesta- 
tions not unlike some of those of preleucemia and premycosis, while 
the halogen granulomata in turn closely resemble some of the infec- 
tious granulomata. Thus we are forced to an admission of ignorance 
of the nature of these diseases, and there is more circumstantial evi- 
dence that they are metabolic in source than that they are infectious. 
In the last analysis we must confess that, since all disease is either 
infectious or not in origin, a discussion of this side of the matter 
to-day is as fruitless as the theme of a school boys' debating society. 

Granuloma fungoides and leucemia cutis have many points in 
common. Both possess early stages characterized by itching der- 
matoses; both exhibit granulomatous phases; mycosis sometimes is 
accompanied by blood changes, leucemia is sometimes without any. 
Thus the two conditions not only are clinically similar but actually 
are often clinically indistinguishable. Again, they clinically often 
resemble sarcoma. In older works mycosis and leucemic granu- 
lomata were called sarcoids, so close to sarcomata are they in appear- 
ance. Our present lack of information thus justifies the belief 
that they are closely related and represent a process sui generis. 

304 



NON-INFECTIOUS GKANULOMATA 305 

The granulomas caused by iodides and bromides are obviously 
non-infectious, and are placed in this chapter because they consti- 
tute a picture which the practical physician must have clearly in 
mind. The other diseases, mentioned above, are rare, but must be 
recognized because of their important bearing on internal medicine. 

GRANULOMA FUNGOIDES (FIGS. 67 AND 68) 

Synonyms. The commoner synonyms are mycosis fungoides, 
lymphadenie cutanee (indicating its unknown origin) ; Entzunaliche 
fungose Geschwulstform, and inflammatory fungoid neoplasm, indi- 
cating its clinical similarity to inflammations; sarcoma lymphade- 
noides myxoides, sarcomatosis cutis and sarcoma cutis multiplex 
idiopathicum, indicating its clinical likeness to sarcoma. 

There are still other names. The only designations in common 
use are mycosis or granuloma fungoides. The only sensible one is 
:the last. 

Definition. Granuloma fungoides is a chronic disease of un- 
known origin characterized by a long course divided into various 
stages. The first stage is one in which there are dermatoses of 
various generic types, followed by an erythrodermatous period, which 
in turn gives way to a tumor stage. The first two phases are un- 
happily called premycosis or premycotic, the final stage fungoid or 
mycotic. It would be better to use the terms prefungoid and 
fungoid. 

Symptoms. Partly for the sake of convenience, and partly be- 
cause it is usually a fact, granuloma fungoides may be divided into 
three stages, an exanthematous, erythrodermal (Fig. 67) and fungoid 
stage (Fig. 68). At first there may be only generalized, more or less 
intense, pruritus. Or there may be transitory but repeated attacks 
of urticarial, vesiculosquamous or erythematous eruptions, the last 
often resembling erythema multiforme. Another early form of the 
disease is parapsoriasis (Chapter XI), or closely related conditions, 
or psoriasiform, " eczematous," bullous, or lichenous eruptions. It 
is common to see such eruptions limited to that part of the body be- 
low the navel, but they may be anywhere. The commonest pre- 
fungoid eruptions are those suggesting squamous dermatitis, psoriasis 
and parapsoriasis. The lesions are festooned, corymboform, scaly 
and itching; or there are gyrate plaques. The lesions tend to be 
bluish red and slightly infiltrated. 

Now the erythrodermatous or infiltrated stage arises, a condi- 



306 DEKMATOLOGY 

tion clinically often indistinguishable from pityriasis rubra of 
Hebra (Chapter XII) or dermatitis exfoliativa of Wilson-Brocq. 
But there is more itching and infiltration. In either of these two 
stages fugacious nodules, varying in size up to that of a dime or 
quarter, appear. They last a few days or weeks and gradually this 
tendency dominates the picture. The nodules develop into tumors, 
some of which reach the size of a mandarin or tangerine. They 
develop rapidly, reach a given size and involute more or less rapidly 
by absorption or ulcerative necrosis. Their shape is often like that 
of a tomato. They are slightly lobular and as often have a con- 
stricted as sessile base. Their color is dusky red, purple or brown. 

While this goes on, the skin grows pigmented, atrophic, or may 
show evidences of the early stages. The tumors arise anywhere, 
but the face, groins, armpits and chest are the favorite sites. The 
tumors may be single or multiple and the patient gradually wastes 
away, although comparatively good health may endure for years. 
General glandular enlargements occur. There is, as a rule, only 
slight if any secondary anemia, often a leucocytosis with diminished 
polymorphonuclear count, and often a marked eosinophilia. The 
range of leucocytes is from normal to 112,000, that of the eosino- 
philes up to 54 percent., while the lymphocytes remain quantita- 
tively normal or are diminished. 

Course. The prefungoid stage may last weeks, months or years, 
as may also the fungoid. Thus the entire period of the malady is 
varied and long drawn out. Although the skin, glands and blood 
usually show the greatest changes, tumors may be present on the 
mucous surfaces in the mouth, on the vulva or conjunctiva. The 
termination is invariably fatal. Occasionally the sufferer dies of 
marasmus, more frequently, however, of some intercurrent infection. 
The entire progress of the disease requires, on an average, from two 
to four years, but it may last for ten or fifteen. 

Varieties. At times the disease starts with the tumor stage, 
without the prefungoid period. This form is called mycosis 
fungoides d'emblee. It usually runs a short course. The lesions 
are the full blown tumors closely simulating sarcomata, and they 
arise in restricted areas on previously healthy skin. They often 
involute without ulceration or necrosis. The ultimate destiny of 
the patient is that seen in the commoner form. 

Differential Diagnosis. In the stage in which the prefungoid 
lesions resemble diverse dermatoses the diagnosis is impossible. An 



NON-INFECTIOUS GRANULOMATA 307 

alert observer will always be on bis guard, however, in cases of in- 
veterate pruritus witbout obvious cause, recurrent urticaria, prurigo, 
and the like. 

Tbe parapsoriatic, squamous (eczema) dermatitis and erythroder- 
matous group of lesions always sbould arouse suspicion of mycosis, 
particularly the first and third in all cases, and the second when 
inexplicably obstinate. As a rule it is impossible to know whether 
these diseases are mycosis until the advent of the fungoid period, 
and then, of course, tbe diagnosis is made in retrospect only. It is 
often possible, though, to reach a definite conclusion in the early 
stages by histological studies. In early mycosis the same anatom- 
ical features are often, though not always, present as in the gran- 
ulomatous period. A detailed description of the microscopic 
picture is not possible in this book, but a few essential points may 
be given. The epidermis resembles that in chronic dermatitis, 
psoriasis or parapsoriasis. An infiltration is present including the 
papillae and subpapillary area. It consists of different types of the 
round cell group, mitotic cells, a peculiar multinucleated cell (the 
chorioplaque) and a variable proportion of eosinophiles. In lepra, 
which may be simulated, there are bacilli; in syphilis, vascular 
changes and plasma cells; in psoriasis, parapsoriasis and squamous 
dermatitis, the infiltration is purely inflammatory. It must be re- 
membered, however, that a prefungoid dermatosis must lack char- 
acteristic anatomical features for a long time, and that an inconclu- 
sive microscopic picture is only temporary and most unreliable evi- 
dence against mycosis. 

In the erythrodermatous eruption, Wilson-Brocq's dermatitis ex- 
foliativa, and Hebra's pityriasis rubra pilaris must be excluded. 
This follows the lines indicated above. In the last analysis the diag- 
nosis of prefungoid dermatoses depends upon the course of the 
disease. 

In the fungoid stage lepra, tuberculosis, syphilis, leucemia and 
sarcoma must be excluded. The histological evidence here too is of 
some value. A fungating lesion roughly may be divided into periods 
of growth, maturity and involution. In the first stage it is anatom- 
ically as described above. In the second it is largely as described, 
but an even amount of evidence of destruction is seen in the pres- 
ence of cell detritus. In the last period there is a predominance of 
cell detritus, or other evidence of necrosis, and no evidence of 
growth. Absence of lepra bacilli, the type of vascular changes and 



308 DERMATOLOGY 

absence of the typical structure of tuberculosis rule out lepra, syphilis, 
and tuberculosis. Xor does the picture resemble that of sarcoma. 
In leucemia the infiltration is lower down and perivascular. All of 
the infectious granulomata may be excluded by the absence of pre- 
fungoid dermatoses. Lepra may further be excluded by the absence 
of nerve involvement, syphilis by the absence of the Wassermann 
reaction and tuberculosis by the occasional presence of bacilli and 
that of the tuberculin reaction. 

Fungus diseases, such as sporotrichosis, blastomycosis and deep 
ringworm are readily differentiated by demonstrating the specific 
organism. 

Sarcoma has no prefungoid stage and rarely are the lesions so 
numerous as in mycosis, except in Kaposi's multiple form which, 
however, is a disease largely restricted to Russian Jews, and dif- 
ferent in coarse, localization, and so on (Chapter XXX , 

Leucemia cannot always be differentiated. It is close to mycosis 
in course, appearance, and other attributes. This will be further 
discussed below. 

Etiology and Pathogenesis. Xothing is known of the cause of 
granuloma fungoides. There are those who believe it to be infec- 
tious, those who consider it a sarcoma and those who regard it as 
a disease of metabolism. Much may be said in support of each view, 
and this very fact denotes the futility of further discussion of the 
topic. 

Treatment. The X-Eays furnish the best treatment. Divided 
loses are preferred. Almost invariably the lesions can be removed 
by this means and kept under control for years. Arsenic either 
by mouth or hypodermic injection is of great value. Symptomatic 
treatment including the dressing of ulcerous lesions, the use of 
antipruritics, tonics, and in late stages anodynes to relieve suffering. 
are obviously indicated as need arises. 

Prognosis. The disease is always fatal, but by wise measures 
the end may be deferred in many cases. 

LEUCEMIA CUTIS EXCLUDING PSEUDOLEUCEMIA 

5. Lymphadenie, Lymphoderma, Perniciosa, Leuce- 
midea 

Definition. Leucemia and pseudoleucemia cutis constitute rare 
conditions in which as a symptom of. or in the course of leucemia or 
pseudoleucemia, dermatoses arise some of which are lymphatic skin 
tumors, true leucemia and pseudoleucemia cutis : and others of which 



NON-INFECTIOUS GKANTJLOMATA 309 

are vaguely associated dermatoses known as the leucemides. The 
leucemides bear the same relation to leucemia cutis that tuberculides 
do to skin tuberculosis. 

Symptoms. Preleucemic dermatoses, not unlike those seen in 
early mycosis, are known. They are as follows: pruritus, prurigo, 
urticaria, simple dermatitis and dermatitis herpetiformis and ery- 
throderma. Pruritus is particularly common in pseudoleucemia 
(Hodgkin's disease) and may persist for years without evidence 
of skin involvement. As the glands enlarge the true nature of the 
disease becomes manifest. The urticarial attacks are fugacious 
but repeated. Prurigo, unlike the true form, arises late in life, 
but is otherwise indistinguishable. The erythroderma resembles 
pityriasis rubra (Hebra). Simple dermatitis is present but ex- 
tremely pertinacious. In pseudoleucemia the blood picture is not al- 
tered, but the glands are enlarged. In acute leucemia there are the 
usual leucocytosis and lymphocytosis; in chronic leucemia there is a 
relative lymphocytosis. In pseudoleucemia, as stated, there are 
glandular enlargements. In leucemia this is also the case, and the 
spleen is enlarged too. According to Arndt leucemia should be di- 
vided into aleucemic, subleucemic and leucemic varieties according to 
whether the blood picture is altered or whether there is merely a 
lymphocytosis or that with a leucocytosis. So far as the aleucemic 
stage is concerned, in its relation to the skin this is nonsense, for 
we cannot call a disease leucemia unless we know that it is. 

The leucemic tumors themselves develop on the face, often giving 
the picture of leontiasis, and on the scalp, about the shoulder girdle, 
or extremities, but rarely on the body. They are purplish, reddish 
or brown, more or less glistening tumors varying in size from that 
of a bean to a hen's egg y and they are usually numerous. Although 
they arise after preleucemic dermatoses such as those mentioned, or 
pigmentations, urticaria or purpuric lesions, they do not arise on 
these as mycosis develops on prefungoid lesions. They do not break 
down, and may or may not disappear. 

Often in acute leucemia, leucemic infiltrations are found in the 
mouth, particularly on the tongue and tonsils. 

Course. The disease is acute or chronic. The acute form either 
ends in death in a few weeks or goes into the chronic form. The 
latter may require years to run its course. 

Varieties. The varieties are the preleucemic dermatoses, the 
granulomata and the leucemides or lymphadenides of Audry. The 
latter may be erythrodermas, or resemble prurigo or dermatitis her- 



310 DERMATOLOGY 

petiformis. They differ from the preleucemic forms clinically sim- 
ilar, in having a leucemic minute structure. The leucemides itch, 
and are often associated with leucemic granulomata. 

Differential Diagnosis. In general the same applies to the diag- 
nosis of leucemia cutis that applies to granuloma fungoides. From 
granuloma fungoides leucemia is distinguished clinically by its tend- 
ency to favor the head and extremities, by the blood picture, larger 
glands and enlarged spleen. However, granuloma fungoides some- 
times has a leucemic blood picture, and aleucemic leucemia, if there 
is such a thing, has no leucocytosis. Under the last conditions, a 
differentiation is impossible. Pseudo-leucemia is distinguished from 
leucemia by the blood picture, except in the aleucemic stage of 
leucemia, and from both leucemia and mycosis by the histology of 
the glands. The structure of the cutaneous lesions is lymphogran- 
ulomatous. This excludes everything diagnostically except lymph- 
osarcoma which cannot always be differentiated. In children 
chloroma gives the cutaneous picture of other forms of leucemia. 

The leucemides resemble prurigo, dermatitis herpetiformis, 
etc., as already stated. They are distinguished from these by the 
blood picture, and may be further differentiated histologically if 
they too have the structure of lymphogranulomatosis. 

Mouth lesions in acute leucemia resemble those of syphilis, tuber- 
culosis and Vincent's angina. The Wassermann test, search for 
tubercle bacilli and Vincent's organisms, as well as the blood count, 
should prevent error. 

Etiology. Nothing is known of the cause of the disease. 

Treatment. This is identical with the treatment of mycosis. 

Prognosis. The prognosis is bad. 

Rare Lymphatic Diseases of the Shin. It follows from what has been 
stated that mycosis, sarcoma, leucemia and pseudoleucemia have many 
points of contrast. At times one cannot be differentiated from the other. 
It is only in typical cases that these rare diseases are interdistinguishable. 
Still rarer ones have been described undoubtedly belonging in this group. 

Leucosarcomatosis Cutis is characterized by lymphogranulomata in the 
skin with a peculiar mononuclear leucocytosis. It is closely related to 
chloroma. Lymphosarcomatosis Cutis consists of more or less localized 
lymphatic skin proliferations similar to those of leucosarcomatosis, but the 
blood picture is normal. Lymphogranulomatosis Cutis is a disease so 
closely related to pseudoleucemia cutis that it is probably a variant of the 
same. Lymphoderma perniciosa Cutis (Kaposi) is a subvariant of mycosis. 
It follows the same course, but the erythrodermal stage is more marked. 
Kaposi's case is the only one on record, and he described it at a time 
when the various forms of mycosis were less well known than now. 




Fig. 67. GRANULOMA FUNGOIDES 

The early manifestations of the disease are scaling erythroderma which gradually 
gives rise to nodules or tumors. Both stages may coexist. Scaling is shown in 
many areas. The scaling lesions are red and sharply circumscribed. Tumors are 
found near the elbows in this picture. 




Fig. 68. LEUCEMIA CUTIS 

In lymphatic leucemia two types of lesions are found. Xon-specifie general 
reactions, called leucemides (Audry) and leucemic infiltrations forming tumors 
or nodules, as here seen. Ihe latter are composed of lymphocytes. As in 
mycosis, a preliminary exfoliative stage is often found. Myelogenous leucemia 
very rarely, and Hodgkin's disease sometimes, produce this picture. 



NON-INFECTIOUS GKANULOMATA 311 

IODODERMA AND BROMODERMA TUBEROSA 

The various dermatoses caused by iodides and bromides bave al- 
ready been described (Chapter VII). The tuberous forms merit 
further attention at this point because in nature's laboratory they 
represent a nice illustration of non-infectious granulomata. They 
are due to overdosage or susceptibility. They occur on the face and 
shins chiefly, and are condylomatous, cribriform, papillomatous or 
granulomatous lesions resembling the various infectious and non- 
infectious granulomata. They vary in size up to an inch or two in 
diameter, are brownish red or purple, often have punctiform ab- 
scesses on their flat upper surface and are recognized by the history 
of drug ingestion and the conventional methods of excluding the 
fungus granulomata, tuberculosis, syphilis, lepra, mycosis, leucemia 
and sarcoma. Bromodermata are found in epileptics, children with 
pertussis, and in nursing infants whose mothers take bromides. Io- 
dodermata are most frequently seen in syphilitics, which augments 
the difficulty of excluding gummata. 

The condition is redescribed at this point because iodides and bro- 
mides are capable of provoking nongranulomatous dermatoses, an 
analogy to the state of affairs in mycosis and leucemia. This is 
suggestive for those of us who seek to explain the causation of the 
major non-infectious granulomata on a toxic basis. The treatment 
of the halogen dermatoses is to stop the ingestion of the offending 
drug. Arsenic hastens involution, and the prognosis is good. 



SECTION D. NEOPLASMS AND NEVI 

NEOPLASMS AND NEVI 

Neoplasms and nevi may with more or less justification be in- 
cluded under one heading. Many nevi are neoplastic; many neo- 
plasms arise from both neoplastic and non-neoplastic nevi. Many 
neoplasms, however, as will be seen, arise from previously inflamed 
or normal tissue. Thus it cannot be stated that the relation of neo- 
plasms to nevi is so close as to exclude the origin of new growths 
from all other sources. And yet a certain intimacy exists between the 
two groups, closer than that of either with any other class of derma- 
toses. For this reason, even though somewhat arbitrarily, they may 
be associated. 



313 



GKOUP VIII. NEOPLASMS 

Neoplasms are new growths the etiology of which is not under- 
stood. There is no conclusive evidence that they are infectious, and 
yet it cannot be denied that this possibility is often suggested. They 
are not due to disturbed metabolism, and yet different types of neo- 
plasms are so much more characteristic to one period of human exist- 
ence than another that a metabolic basis for their origin cannot be 
ruled out. They are not definitely hereditary, and yet in a sense, 
and in so far as they are related to congenital anomalies, they may 
be. They are not definitely toxic in origin, and yet human life is 
so greatly a chemical drama that who will deny the possible bearing 
of metabolic disturbances upon the pathogenesis of neoplasms? 
They are surely not due to physical causes but physical factors play 
as large a role in life as chemical, and is it not striking that cuta- 
neous cancer so frequently develops on the lips in men, or in the 
breasts in women, or on the face in both? It is possible that the 
clinical picture of neoplasms may be an expression of different forces, 
and that as the various causes are isolated this tumor will be re- 
garded as infectious in origin, that as congenital, the third as toxic, 
and so on. 

Neoplasms are benign or malignant and these factors depend arbi- 
trarily upon their curability, and the amount of harm they do to the 
patient either locally, by extension, or remotely, by metatasis. They 
are of connective tissue origin or epithelial origin, according to 
whether they arise in the mesoblastic elements of the skin or in one 
of the skin's many ectoblastic structures. There is another group, 
the melanomata, sometimes showing characteristics of mesoblastic 
origin, sometimes of ectoblastic, sometimes of both, but always char- 
acterized by a great number of pigment cells and nearly always by 
great malignancy. In a sense the infectious granulomata are neo- 
plasms. We may exclude them, however, because we know their 
etiology. 



315 



CHAPTER XXVII 

BENIGN EPITHELIAL NEOPLASMS 

Benign epithelial neoplasms are new growths arising in the epi- 
dermis and devoid of harmful potentialities. These new growths 
may be single or multiple, and there are several varieties, namely the 
different warts. Warts are also called verrucae, and in French 
verrue, and German, Wartzen. 

Verruca vulgaris or simple wart is a hypertrophic epithelial 
lesion appearing chiefly on the hands, about the nail bed, and some- 
times on the face, genitalia, or finally, anywhere else. The lesions 
are from two millimeters to a half inch in diameter, single or mul- 
tiple, and when multiple often grouped or even coalescent. They 
are yellow, gray or brown, smooth or rough and sometimes cleft, 
forming digitations giving them the appearance of a stubby brush or 
coxcomb. They are non-inflammatory but may become inflamed by 
irritation, unskillful treatment or infection. In this event their base 
becomes red and they are painful and tender, although ordinarily 
warts, are not sensitive. The cause of the disease is unknown. 
Certain evidence, chiefly apparent autoinfect ability, suggests an in- 
fectious origin. At times tuberculosis verrucosa cutis is simulated. 
In such cases microscopic examination alone would clear up the 
diagnosis. The youth of the patients excludes the likelihood of 
epithelioma, but at times skin cancers begin as warts. The treat- 
ment consists of removal by means of the knife, curette, high fre- 
quency spark or X-rays. The last two methods are the best. Of 
caustics only trichloracetic acid is to be recommended. About the 
nail bed or near the eye, X-rays represent the method of choice. 
The high frequency spark is faster but more painful. 

Verruca plana juvenilis is a disease chiefly of infancy and child- 
hood, and rarely seen in adults. Xumerous yellow glistening warts 
appear, chiefly on the face, neck and backs of the hands, although no 
part of the body is immune. There may be few lesions or hun- 
dreds. They are so minute as to be barely visible, and rarely ex- 
ceed a diameter of two millimeters. They are discrete, clustered 
or coalescent and no subjective symptoms are present. At times sev- 

316 



BENIGN EPITHELIAL NEOPLASMS 317 

eral children in a family are affected. They are infectious and 
Wile has found a filtrable virus. The high frequency spark or the 
use of trichloracetic acid constitute the best therapy. Arsenic in- 
ternally is also most valuable. 

Verruca dorsi manus et pedis are large flat warts on the back of 
the toes and fingers, particularly the index fingers and thumbs. The 
warts are found in the middle aged and old. They are treated as 
verruca vulgaris. 

Verrucae or keratoses senilis, also known as seborrhoeic warts, 
are lesions up to a half inch in diameter. They occur from middle 
age up, chiefly on the nose, temples and neck, but also anywhere else 
on the face and often on the body. They are greasy, yellow, gray, 
brown or slate colored, slightly elevated, scaly lesions. On remov- 
ing the scales a slightly glistening red serous surface remains. They 
are often the forerunners of epitheliomata and are easily cured by the 
use of salicylic acid plaster or trichlor-acetic acid. 

Verruca filiformis is a minute brown wart looking like a small 
thread, a millimeter or two long, and a fraction of a millimeter 
broad. It occurs in multiple lesions chiefly on the neck, chest and 
face of women. A similar form which usually disappears spon- 
taneously after confinement, is seen in gravidae. The late Samuel 
Brickner regarded this type as molluscum molle. As a matter of 
fact it is hard to tell whether these lesions are really warts, papil- 
lomas or fibromas, as they correspond to one papilla covered by 
epithelium. The best way to cure them is by ablation or the high 
frequency spark. 

A peculiar form is one that might be called verruca multiplex 
barbae. It occurs in men who shave close. The bearded region is 
the site of a few or innumerable flat yellowish lesions resembling 
verrucae planae. They arise near or above a hair follicle and often 
contain an ingrown hair. The only successful therapy is the use of 
the high frequency spark. 

Treatment. In employing the high frequency spark a spark of % 
to % of an inch is used. For small lesions the spark should be 
allowed to jump from the electrode to the surface to be treated. This 
swells and turns white in a few seconds. For larger lesions the 
electrode should be firmly pressed in and the spark allowed to play 
for about 20 to 30 seconds till the lesion is white and bubbly. It is 
better to be conservative and repeat the treatment than to be too 
drastic and leave a depressed scar. After a day or so the treated 
lesions turn brown, a crust having formed which falls off within ten 



318 DEKMATOLOGY 

days. Warts of the nail bed should be treated carefully by this 
method, as too destructive an exposure causes disfiguration of the 
nail. Some warts recur no matter what treatment is used. In these 
varieties, as well as in warts so situated as to make other treatment 
unfeasible, X-rays are indicated. A single exposure of four Holz- 
knecht units often suffices to cure. 

Connected with verrucae, as with so many other dermatological matters, 
there is some technical jargon that must be mentioned. Verruca acquisita 
means a wart acquired after birth. Verruca congenita is a variety of 
nevus (Chapter XXXII). Verruca digitata indicates a fingerlike pro- 
liferation of the papillae composing the wart's structure. Verruca glabra 
is a smooth wart. In addition to this must be mentioned verruca acum- 
inata already described among the dyskeratoses (Chapter XIV) under the 
better name condyloma acuminatum; verruca necrogenica or tuberculosis 
verrucosa cutis (Chapter XXV) and verruca peruana (Chapter XXI), 
neither of which are warts, but an infective granulomata that looks some- 
what like warts. 



CHAPTER XXVIII 

MALIGNANT EPITHELIAL NEOPLASMS 

Malignant cutaneous epithelial neoplasms are new growths which 
originate in the ectoblastic elements of the skin. Hence they may 
arise from the epidermis, the pilosebaceous or sweat organs. It is 
not, however, their embryological source that determines their malig- 
nancy, for mesodermal tissues are also capable of producing equally 
vicious neoplasms. Malignancy is determined by the effect of the 
growth on the host, and the concept is relative. In other words there 
are degrees of malignancy. A rodent ulcer is malignant because it 
does not heal. Neither does it form metastases, however, and in this 
respect it is less malignant than a prickle cell epithelioma of the 
lip which metastasizes and kills. A rodent ulcer of the eyelid which 
ultimately destroys the eye is more malignant, so far as the patient 
is concerned, than a rodent ulcer of the chest which can do little 
actual harm. But by destroying the eyelid, and thus causing second- 
ary changes in the eye and orbit, an inflammatory process may 
arise capable finally of causing meningitis. Thus such a rodent 
ulcer has incidental malignant attributes which have no direct con- 
nection with the epithelioma as such. In the human sense such a 
growth is malignant, but not in the biological. It is no worse than 
lupus vulgaris, or a gumma of the nose. On the other hand, a prickle 
celled epithelioma is worse than either. Its inherent properties are 
sinister. In forming our ideas of malignancy it is therefore neces- 
sary to distinguish between growths, the very nature of which is 
disastrous to the patient because of certain constant peculiarities, 
and growths which are disastrous because of incidental peculiarities, 
such as those of localization or size. 

The malignant epitheliomas include, or rather are, that group of 
neoplasms also called carcinomas. Technically a wart is an epi- 
thelioma, though benign, but we eliminate confusion by calling warts 
vurrucae, and by understanding the important fact that in growth a 
wart is regular, and that the epithelial cells never become anarchistic 
as in malignant epithelioma or carcinoma. Another name for mol- 

319 



320 DERMATOLOGY 

In scum contagiosum is epithelioma molluscum, and in so far as this 
condition is an epidermal neoplasm it is an epithelioma with the 
same restrictions as a verruca. Epithelioma adenoides cysticum is 
no epithelioma at all, but a condition sui generis, and perhaps a 
nevus (Chapter XXXIII) . With these exceptions we understand 
by the term epithelioma a peculiar growth of epiblastic or ectodermal 
ancestry, capable of wild proliferation both locally and afar, and 
harming the individual in whom it develops partly by local destruc- 
tion, partly by becoming disseminated, and partly by leading to 
cachexia. In one of these three ways it kills either directly or in- 
directly. 

Among epitheliomata, or closely related to them, are melanomata 
and endotheliomata. In coming years, when the latter are better 
understood, they may resume the independent position they once 
held. They were originally supposed to arise from vascular endo- 
thelium, and perhaps, indeed, they do. This has been doubted, and 
many conditions regarded as endotheliomata have turned out to be 
baso-cellular carcinomas. Xevertheless enough remains substan- 
tiating belief in endotheliomata to warrant retaining the term, while 
sufficient evidence exists against the belief to warrant including 
endotheliomata in a chapter upon epithelioma. This would not be 
justified in a more philosophic work than the present book, and the 
arrangement is convenient rather than scientifically accurate. 

EPITHELIOMA 

Synonyms. Cancer. Carcinoma. Cancroid; French Cancer, Carci- 
nome. Epitheliome : German Krebs, Karzinom, Epitheliom. 

Definition. Epithelioma or cancer of the skin is a more or less 
malignant epithelial new growth characterized by a tendency to un- 
restricted proliferation with the ability, in certain forms, to invade 
local or remote glands, or to form matastases. There are primary 
types, of which the above is a definition, and secondary types, which 
are skin metastases derived from neoplasms elsewhere. 

The symptoms and course of epitheliomata differ in the different 
types so that each variety will be considered individually in these 
respects, in a manner not conforming with the general arrangement 
of this book. Many classifications are to be found in the literature, 
and for the deep student all have interest. For the practical clin- 
ician, however, no classification excels that of Darier, which, with 
some modification, will serve as a model. It will further simplify 
matters to consider cutaneous and mucous surfaces separately. 



MALIGNANT EPITHELIAL NEOPLASMS 321 

Cutaneous Epithelioma 
I. Primary. 

1. Prickle Celled. 

A. Deep type. 

B. Superficial vegetating type. 

a. Hyperkeratinized form. 

b. Denuded type. 

2. Basal Celled. 

A. Flat Cicatricial form. 

B. Rodent Ulcer. 

C. Deep ulcerating form. 

D. Cylindroma. 
II. Secondary. 

1. Papulo-tubercular. 

2. Cancer en cuirasse. 

3. Paget's disease. 

4. Acanthosis nigricans. 
III. Pigmentary epithelioma. 

1. Primary or nevo-epithelioma Melanoma. 

2. Secondary or metastatic melanoma. 
IV. Endothelioma. 

MUCOUS AND MUCOCUTANEOUS EPITHELIOMA 

1. Buccal and palpebral. 

2. Male and female genitalia. 

3. Perianal. 

PEIMARY CUTANEOUS PRICKLE CELL EPITHELIOMA (EIGS. 69, 

70, 72, 73) 

Synonyms. Squamous celled, lobular epithelioma ; Erench Epi- 
theliome Spinocellulare, Epitheliome Lobule; German, Easernepi- 
thelkrebs; Latin, Epithelioma spinocellulare. 

Definition. Cutaneous prickle celled epithelioma is a malignant 
neoplasm originating from the prickle layer of the epidermis. It is 
characterized histologically by the presence of epithelial pearls and 
other evidences of complete keratinization. Clinically it shows a 
marked tendency to voluminous growth and lobulation, with or with- 
out necrosis, and in its course it tends to be most malignant, usually 
involving the regional lymph glands, and throwing out metastases, 
however rarely, to remoter regions of the body. 



322 DEKMATOLOGY 

Symptoms. The disease begins as a small scaling papule, large 
papule, or abrasion on the normal skin, or upon one of the so-called 
precancerous lesions. It grows very rapidly or extremely slowly, 
or at first remains stationary and then grows more or less rapidly. 
Scales or crusts form which adhere firmly and, when forcibly re- 
moved, leave a glazed, oozing or bleeding, red surface surrounded by 
a more or less dense raised margin which tends to roll and is pink, 
red or buff. The margin is hard and the entire lesion feels so too, 
when pinched. As times goes on the surface becomes lobulated (Fig. 
69) and the lesion is red, purple or brown. The lobulations are ir- 
regular in size and volume, sometimes resembling hypertrophic gran- 
ulation tissue, sometimes cerebriform, sometimes suggesting cauli- 
flower, but always bleeding easily with the slightest trauma. A 
serous or sero-purulent substance is secreted which dries easily into 
yellow, gray or dirty brown adherent crusts. Very often necrosis 
takes place and a crateriform ulceration develops, the floor of which 
has the characteristics mentioned above, the margin of which is un- 
dermined and vegetating or rolled. Pressure of the mass causes the 
extrusion of fusiform or caseous wormlike particles consisting of cell 
detritus or cheesy pus. The extension is not only on the surface but 
downward, and it involves any deeper tissues, even bone, that seek 
to obstruct it. Regional glandular involvement usually takes place, 
and rarely general metastases are encountered. The glands are hard. 
The growth hurts and pains, but the glands do not, as a rule. Three 
fourths of these cancers appear on the scalp and face, largely near the 
lips. The remaining quarter appear anywhere else on the body, but 
chiefly near the muco-cutaneous junctions. An entire lip or eyelid, 
the glans or anal margin may be melted away. 

Course. The course may cover months or years, but is always 
very rapid after the vegetating stage has set in. 

Varieties. There are two varieties, the papillary or hyperkeratin- 
ized form, and the papillary form devoid of epithelium. The former 
may occur anywhere but usually arises on the face, lips or neck, and 
at times on the exterior sides of the extremities, hands, feet and 
digits. Its origin is commonly in a senile wart. It grows with ex- 
treme deliberation, crusts, scales, fissures, bleeds, ulcerates, and 
finally assumes the features of the deep type described above. 

The denuded variety is largely confined to the muco-cutaneous 
junctions; is voluminous, red, velvety, glazed, and finally is con- 
verted into the deep variety following the latter 's course. 

Diagnosis. The diagnosis rests upon clinical and microscopic 



MALIGNANT EPITHELIAL NEOPLASMS 323 

data. Clinically the long duration of the disease, the fact that a 
preceding dermatosis (senile wart, scar, leucoplacia, lupus vulgaris, 
etc. ) existed, the appearance of the growth, its site, and the glandular 
involvements are the significant points. The histological appear- 
ance is characteristic and serves as the proper guide for all differen- 
tial diagnosis. It must he remembered, however, that the probatory 
excision is not without danger, as biopsy frequently stimulates 
growth. Thus small lesions should be excised in toto and examined, 
the excision being the therapy. The excision of large lesions is a 
pretentious operation. Thus small pieces should be removed and 
examined immediately in frozen sections, the patient awaiting the 
report, and the surgeon prepared forthwith, upon an adverse verdict, 
to remove the growth and to extirpate the regional glands. Should 
the findings be negative the growth should nevertheless be entirely 
removed provided all other confusing conditions have been excluded. 
Thereupon a most searching histological study should be made, and 
if a diagnosis of malignancy is reached the local glands should soon 
be extirpated and examined for metastases. 

Early epitheliomata clinically resemble warts, and ulcerating epi- 
theliomata resemble tuberculosis, syphilis, the fungus granulomata 
and other malignant growths. The histology is characteristic in all 
instances. Syphilis should be excluded on clinical and sero-logical 
grounds, but the positive Wassermann test does not exclude the 
possibility of cancer arising in a syphilitic. The finding of specific 
pathogenic organisms in the various infections is conclusive. 

Etiology and Pathology. To discuss the etiology of epithelioma 
is futile, as nothing definite is known. Despite an outlay of millions 
of dollars for cancer research, and an incalculable cost of time and 
intellectual energy our grandfathers knew as much of the causation 
as we do. A few facts stand out, Epitheliomata usually arise 
during and after middle age. Some types, as the labial for example, 
are commoner in males ; others, as the mammary, in females. Men 
smoke and women suckle, so that the trauma appears to play a role. 
For the most part the growths develop on the face where glandular 
activity of the seborrhoeal sort is common ; thus functionally active 
epithelium appears to be a favoring item. Certain conditions known 
as precancerous dermatoses are predisposing causes. This question 
will be considered in detail in the next chapter. Certain kinds arise 
in nevi. Followers of Cohnheiin's views believe that all epithe- 
liomas, including those of nevus origin, spring from embryonal cell 
inclusions predestined to cancerous eventualization. Some writers 



324 DERMATOLOGY 

ascribe the disease to infection. Sponsors of this view have suc- 
ceeded in proving it about as well as alchemists succeeded in their 
labors for synthetic gold. That a metastazing epithelioma has many 
features suggesting infection is true enough, but this attribute is 
confined to the growth, and the transplantation occurs in the host. 
There is not an authentic instance recorded of one person's hav- 
ing infected another, nor has the presumptive agent been isolated. 
Heredity too is invoked on the usual specious grounds, but no true 
evidence thereof exists save that it has been known to occur in several 
members of a family. This may also be said of corns, bunions, 
chronic nephritis, and gout, and yet who ascribes these diseases to 
heredity? Epithelioma is a common disease and it therefore may 
be assumed that familial instances need no further explanation than 
coincidence. Bulkley ascribes cancer to excessive proteid ingestion. 
This is arrant nonsense. 

Treatment. Little need be said about treatment. The method 
of election is extirpation both of the growth and the invaded glands. 
Undoubtedly X-rays and radium cure many cases, particularly when 
the lesions are still young and small. On the other hand, under 
these conditions there is certainly no good reason to give excision a 
place of second rate importance. Radiotherapy is to be preferred 
only when patients decline surgery or when surgery would cause a 
cosmetic defect, as would often be the case in facial growths. Radio- 
therapy is always indicated after surgery as a prophylactic measure. 
When X-rays are employed to destroy a growth a massive dose of 
eight Holzknecht units should be given. When used prophylacti- 
cally, after excision, the scar and region of the removed glands should 
be irradiated two or three times at weekly intervals by the cross fire 
method and with one or two Holzknecht units at a time. Equiv- 
alent doses of radium may be employed, but radium has no essential 
advantages over the Roentgen ray. 

In other times chemical agents, curettage, fulguration and the 
actual cautery were used. These methods have been, in general, 
discarded. The only valuable chemical agent is acid nitrate of 
mercury. The skin is cocoainized, the growth thoroughly curetted, 
a sixty percent, solution of the mercurial salt is swabbed over the 
bleeding surface, and after a moment a dry dressing of pure sodium 
bicarbonate powdjer, affixed firmly, is applied. The bicarbonate 
neutralizes the mercury. A scab develops which falls off in about 
two weeks. This method is useful in people who refuse surgery and 
fear the X-rays, The actual cautery is as good as the knife when 



MALIGNANT EPITHELIAL NEOPLASMS 325 

broadly applied, but the cosmetic result is horrible. Simple curet- 
tage and fulguration have been abandoned as they appear to stim- 
ulate recurrences. 

Prophylaxis is important. People at the age subject to epithe- 
lioma should be cautioned to consult reliable physicians for skin 
lesions that grow or show no tendency to disappear. They should 
be cautioned not to pick, irritate or treat inexpertly such lesions. 
Physicians examining such patients should take nothing for granted, 
but should excise the lesions, and after a microscopic examination has 
been made should select suitable therapy. 

Prognosis. In early lesions the prognosis is good provided the 
treatment is wise. Excision is the best. Even so, local recur- 
rences may take place or metastases may arise from glands early 
invaded. Late growths always render the outlook grave because the 
glands are likely to have become involved. Untreated prickle celled 
epitheliomata always are fatal. 

BASAL CELLED EPITHELIOMA (FIG. 71) 

Synonyms. Eodent Ulcer, Noli Me Tangere, Jacob's Ulcer, Ulcus 
Kodens, Cancroid. 

Definition. Basal celled cancer, of which the rodent ulcer is the 
best known example, is a superficial epithelioma the course of which 
shows great chronicity. It tends to cicatrize and at times is capable 
of spontaneous healing. In that it neither involves the lymphatics 
nor metastasizes it is biologically benign; in that it may cause pro- 
found destruction, and in that it may become the gateway of fatal 
secondary infection it is potentially malignant. 

Symptoms. The growth begins slowly, as a rule, on the face, 
particularly the temples, near the canthi of the eyes, nose, naso- 
labial fold or on the ears. Its first stage is a papule arising on 
previously normal skin, or on pre-existing lesions such as abrasions, 
warts, verrucous nevi, senile warts or in chronically desquamating 
areas near sebaceous glands. The papules are minute and waxy in 
appearance while their color is yellow, buff, reddish or a muddy 
gray. The papule extends circumferentially and breaks down cen- 
trally. Its growth is indolent indeed, and may become stationary 
for months or years at any stage. The central ulceration is covered 
by a firmly adherent crust, the removal of which discloses a yellowish 
red, slightly moist, varnished looking and extremely shallow, saucer 
shaped base, which either rapidly crusts again or even cicatrizes 
gradually. The margin is flat or rolled and, as a rule, is studded 



326 DERMATOLOGY 

with elevations looking like the original papules, but tending to re- 
semble pearls. 1 This is the pearly margin of the rodent ulcer and is 
distinctive thereof. The margin is red, pink or yellow, hard, and 
shimmers with a waxy lustre. The scar may be smooth or slightly 
corrugated. 

The massiveness, verrucosity and lobulation, and the undermined 
margin of the prickle celled growths are lacking in the less volum- 
inous and superficial surface neoplasm called basal cell epithelioma. 
At times the scarring takes place completely within, while only the 
characteristic margin, extending in festooned, circinate or gyrate 
manner, indicates peripheral activity. Such lesions suggest the 
tubero-papular, ulcerating syphilide. Xo glandular involvement or 
metastases occur. 

Course. The lesions are indolent, their evolution sometimes 
requiring years, decades or even a generation, during which time 
the diameter of the growth may not exceed an inch, or it may include 
half the face. Although spantaneous healing may rarely occur the 
lesions usually progress indefinitely unless properly treated. 

Varieties. The discoid form begins as does the type already 
mentioned. It often throws out neighboring daughter lesions. 
Otherwise it behaves as the rodent ulcer. It may, however, when 
stimulated, become malignant, assuming the attributes of the prickle 
cell form. A subvariety of the discoid form is the morphoea-like 
or sclerodermatous epithelioma which looks like a circular disc, the 
diameter of which may reach an inch, and which suggests card- 
board implanted in the cutis. This growth is white or yellow, 
traversed by dilated vessels, and marginated by " pearls." It too 
grows indolently and may exulcerate. Hutchinson described a 
crateriform ulcer in this group, characterized by deeper involvement 
than that ordinarily found, but with the usual type of margin. A 
massive variety with little tendency to ulcerate favors the scalp. 
Microscopically this form consists of tubularly arranged rows of 
basal cells. This is the cylindroma of Billroth and Melassez often 
confused with endothelioma or sarcoma. It is benign. 

Differential Diagnosis. The slow growth, benignity, tendency 

i The use of the word pearls in this connection is one of those mishaps of 
nomenclature so unfortunate in scientific language. It causes confusion with 
the term epithelial pearls found microscopically in spinocellular epithelioma, 
while rodent ulcer is never spinocellular. The use of the word in basocellular 
epithelioma distinguishes a clinical feature. Actually the microscopic epithelial 
pearls of prickle cell cancer suggests onions, and the clinical pearls of rodent 
ulcer resemble little globules of wax. 



MALIGNANT EPITHELIAL NEOPLASMS 327 

to scarring, and appearance, render the clinical diagnosis easy. The 
only two conditions with which it might be confused are syphilis and 
spinocellular epithelioma. The last consideration is academic. A 
microscopic examination would clear away all doubt. 

Etiology and Pathogenesis. There is nothing already stated 
of prickle celled carcinoma that does not apply to the basal cell 
type. Nothing is really known of the causation. 

Treatment. The therapy corresponds to that of the more malig- , 
nant form. Recurrences are rarer than in the latter. 

Prognosis. With proper therapy the cases are practically al- 
ways curable. 

SECONDARY CUTANEOUS EPITHELIOMA 

This group of cutaneous carcinomata arises by involvement of the 
skin through dissemination of malignant metastases from a primary 
focus elsewhere in the organism. The daughter growths may be 
conveyed by means of the lymphatics from great distances to the 
skin, or may involve the skin by direct extension. A rectal neo- 
plasm, for example, may become cutaneous by downward prolifera- 
tions. Microscopically the cutaneous lesions exhibit the attributes of 
the parent neoplasm. The skin metastases may ulcerate or not. 

Papulo-tubercular carcinoma is that metastastic form in which 
malignant deposits are lodged subcutaneously, and grow in situ, 
forming lesions of all sizes, prevailingly up to a half inch in diameter, 
although some grow as large as an egg. The lesions are convex, 
hard papules or nodules. Their color is buff, brown or purple. 
They lie in the subcutaneous tissue or corium and push up the 
normal skin which is traversed by dilated vessels, in a manner quite 
characteristic of the disease. They are the far flung descendants of 
remote visceral ancestors whose native structure is microscopically 
revealed in the cutaneous growths. They may also arise as re- 
currences in scars of extirpated rectal, mammary or cutaneous neo- 
plasms. 

A special variety of this form, which may be primary or secondary, 
is cancer en cuirasse or scirrhous carcinoma. The lesions develop as 
shiny buff or red lenticular papules which coalesce over the whole 
chest or abdomen, into a hard surface. The skin feels leathery and 
binds down the ribs so that respiration is impeded. The entire 
growth suggests, in shape and localization, the breastplate of heraldic 
armor; hence its name. The margin is indistinct and throws out 
proliferations. Because of lymphatic infiltration and involvement 



"2S DERMATOLOGY 

of the axillary glands and vessels, edema or elephantiasis of the 
upper limbs is provoked. The skin is shiny, yellow, red. telangiec- 
tatic and at times ulcerated. The entire body may be involved. 
Fortunately the disease is rare, as it is invariably fatal. The only 
therapy is the use of X-rays. 

Paget's disease or eczematous epithelioma of the nipple is rare. 
It begins, or rather first is observed, as a serous dermatitis of the 
nipple, and later mammary cancer of a highly malignant type, in- 
vading the skin, develops. The exact interrelationship of the two 
processes is not understood. Women are affected more than men. 
Extra mammary forms have been described. 

Acanthosis nigricans (see description Chapter XV). This dis- 
ease in adults denotes carcinoma of the abdominal viscera. TTith 
removal of the internal growth the cutaneous condition has been 
known to have disappeared. The disease is in no sense epithelioma 
itself, but is provoked by visceral tumors of this character. Thus 
it is mentioned at this point. It is rare, but significant, and its 
existence should not be forgotten or overlooked by the alert clinician. 

PIG-MEXTABY EPITHELIOMA OE MELANOMA (FIG. 76 

Pigmentary epitheliomata are primary or secondary. The pri- 
mary forms arise from pigmented moles and are usually single. Any 
part of the body may be the site. The lesions are slate gray, blue, 
brown or black and assume the appearance of the deep or prickle 
celled epithelioma. Thus they are verrucous, papillomatous, cauli- 
flower shaped, or corrugated, and often ulcerate. They are rare, 
highly malignant, matastasize throughout the body or into the skin, 
and structurally resemble the nevi from which they spring, plus 
epithelioma containing large numbers of pigment cells. 

The secondary variety arises in much the same way as any other 
secondary epithelioma, from mother neoplasms of the pigmented 
type. This form is multiple from the outset starting as tiny dark 
brown or black dots which grow into the fungating form. Both 
types are highly malignant. The treatment is the same as that of 
ordinary epithelioma, but the prognosis is always bad. 

ERDOTHELIOMAi 

Theoretically endotheliomata are not particularly malignant neo- 
plasms, originating from vascular endothelium. Spiegler's cases 
were probably true specimens of the disease. The lesions vary in 
size, some reaching the dimensions of a small orange, but the ma- 



MALIGNANT EPITHELIAL NEOPLASMS 329 

jority being smaller. They favor head, neck and trunk, and are 
usually multiple. They are resistant but not stony hard, and they 
show wide variations in color from orange to blue or purplish. They 
grow slowly. Often there is a close histological similarity to basal 
cell epithelioma. The entire subject is still vague. 

MUCOUS AND MUCO-CUTANEOUS EPITHELIOMA 

Mucous and muco-cutaneous epithelioma are prevailingly of the 
prickle cell type and thus very malignant. They easily recur or 
form metastases, and if treatment is begun too late, they kill. In 
clinical respects they show no difference from the cutaneous growths 
of like type. Certain peculiar details, however, deserve special 
mention. Only the commoner forms will be discussed. 

Epithelioma of the Lip. This disease is seen much more in 
men than in women. Thus it is possible that smoking is a causative 
factor. Regional lymphatics are rapidly involved and the course of 
the malady is highly malignant. The only proper therapy is radical 
excision and extirpation of the affected glands. Subsequent X-ray 
treatments, designed to prevent recurrences, are to be advised. 

Epithelioma of the Tongue.. This variety is also commoner in 
men than women, but the ratio between the two sexes is not so great 
as in the labial form. Whereas the growth is usually single there 
may be multiple lesions. The site is on the dorsal aspect near the 
edge of the tongue, opposite the six-year molars. As a rule a crater 
like ulcer, voluminously infiltrating the tongue, is exhibited. The 
lesion is extremely hard, often tender and frequently instead of an 
ulceration a fungating mass is present. A syphilitic leucoplacia often 
furnishes the starting point. The glands are involved early and 
rapidly. Ptyalism is present, and a suggestive symptom is severe 
pain radiating to the ear on the side corresponding to the lingual 
lesion. 

Tuberculosis and syphilis may be confused with cancer of the 
tongue. Tubercular ulcers are multiple, more superficial, the mar- 
gins are not rolled, but shallow and delicately grooved, and the site 
is nearer the tip, on either the upper or lower surface. It is easy 
to find tubercle bacilli in smears from the ulcers. 

Gummata are usually multiple and dorsal, otherwise they closely 
resemble cancer. Inasmuch as lingual cancer so often arises in 
specific cicatrices, leucoplacia or from gummata themselves, a posi- 
tive Wassermann test does not exclude malignancy, and unless this 
fact is clearly understood serological diagnosis, here applied, is a 



330 DEKMATOLOGY 

menace. Only a negative Wassermann test is of value as favoring 
cancer. If the serum test is positive arsphenamin should be given 
diagnostically, and if after two injections at a week's interval the 
growth has not involuted to half its original volume or less, it ought 
to be wholly excised, examined at once in frozen section, and upon a 
diagnosis of malignancy the already anesthetized patient should im- 
mediately have his tongue resected and the involved glands extir- 
pated. Roentgen therapy should follow. A physician temporizing 
in this matter should regard gently Cain, Nero, Attila or Lucretia of 
Borgia. 

Lingual gummata do not cause glandular enlargements as does 
carcinoma. The prognosis of the disease is always bad, and only in- 
telligence and prompt action on the physician's part furnish to the 
patient a fighting chance. 

Lingual cancer may also simulate a chancre. The same general 
problems are involved as with gummata. In a chancre there are 
enlarged glands, no pain in the ear, and the lesion, when it looks 
like a cancer, is likely to be so advanced that there are already evi- 
dences of secondary syphilis. The Wassermann reaction may be 
present Spirochaetes may be found, but their identification is diffi- 
cult because of their resemblance to spirochaeta microdentium. The 
therapeutic diagnostic test should be made if necessary, the subse- 
quent procedure and therapy being similar to what has been stated 
above. 

Cancer of the penis, aside from melanoma, is usually of the 
ordinary squamous cell variety. It too resembles gumma and chan- 
cre and the differential diagnostic points are the same, and have the 
same significance, as in linguinal carcinoma. Finding the spiro- 
chaetes is easy and is of great value in diagnosis. Malignant neo- 
plasms of the vulva are usually prickle celled and the questions in- 
volved differ in no wise from those already discussed in other parts 
of this chapter. 

In conclusion it may be reemphasized that the diagnostic problems 
connected with cutaneous cancer throw a tremendous responsibility 
upon the physician. If he is not prepared to meet them intelli- 
gently he should not fail to seek proper aid. Early recognition often 
converts malignant potentialities into benign ones, and there is no 
excuse for errors, for the matter is simple, straightforward and with- 
in easy grasp of average intelligence. 



CHAPTER XXIX 

THE SO-CALLED PRE-CANCEROUS DERMATOSES 

Over twenty years ago Dubreuilh classified into a group certain 
cutaneous affections which he regarded as forerunners of epithelioma. 
He designated them as pre-cancerous dermatoses and his views were 
accepted without critical analysis because in many instances the 
facts as conceived by him were true enough. In 1912 Bowen of 
Boston described a condition as the " precancerous dermatosis." 
This malady was sufficiently characteristic in its objective attributes 
to warrant isolation as a clinical entity, and cases were described by 
Darier in Paris and by the author of this book in New York. There 
are now seven instances of the malady on record. Critical study 
of the cases, however, indicates clearly that since four were actually 
cancers they could scarcely be termed precancerous, and since the 
remainder showed nothing epitheliomatous it was gratuitous to call 
them precancerous, in that there was no way of foretelling whether 
they would ever become malignant or not. 

Thus it appears absurd to accept the designation " precancerous " 
into our dermatological vocabulary. It is perhaps meticulous to 
be a purist as to scientific diction, but the term " precancerous " ap- 
pears to be peculiarly vicious since it contains implications at vari- 
ance with fact. Precancerous means a condition invariably ter- 
minating in cancer. Applied to dermatoses we know that this is not 
true. We know that very few lesions of this sort ever become malig- 
nant. We know, too, that epitheliomata as frequently arise from 
apparently normal as from abnormal skin. This being so, why not 
call skin itself precancerous, or, to bring out the absurdity more 
clearly why not call the human being precancerous? Why not call 
smoking a precancerous habit, or lactation a precancerous function, 
or the fifth decade of life a precancerous decade, or chimney sweep- 
ing a precancerous vocation ? Or if we wish to apply the principle 
broadly why not call raw oysters a pretyphoid diet, Peyer's patches 
pretyphoid structures, or streptococcus tonsillitis a prerheumatic or 
prenephritic disease? We do not because these concepts are mani- 
fest nonsense. 

331 



332 DERMATOLOGY 

The early stages of a cancer may look like a seborrhoeal wart, 
but not every seborrhoeal wart becomes a cancer — in fact a very 
small proportion do. There is nothing in the clinical appearance or 
minute structure of a given precancerous lesion that enables a justi- 
fiable prophecy as to future malignancy to be made, and more than 
we can select a particular point on the normal skin with reference 
to such a prediction. A further danger in employing so unsound a 
term as precancerous is a purely human one. People have a well- 
grounded horror of the word cancer. The average person collapses 
when told he has a precancerous lesion. It is impossible for a 
layman to know what the term really means, and it suggests such 
things as the guillotine, coffin or eternal damnation. It is enough 
to advise a patient to have a suspicious lesion removed without 
frightening him with a meaningless word. The expression " pre- 
cancerous " has little, either humane or scientific, in its favor. 

What little there is of scientific sense must also be mentioned. 
There are certain skin lesions which more frequently terminate as 
cancer than other skin lesions. These have been termed precancer- 
ous. The expression should not be regarded as implying that they 
always become malignant, for in comparison with the number that 
do, infinitely more do not. Thus what we really mean in employing 
the word is that we are designating a cutaneous manifestation which 
has, in all human experience, certain well defined malignant pro- 
pensities. Unquestionably a cancer does not spring up spontan- 
eously, and in retrospect it is perfectly reasonable to believe that a 
cancer must have had a precancerous phase. But when it was in 
this phase, or when it ceased to be precancerous and became a 
cancer, we are unable to state of any growth. There is no name to 
substitute for precancerous as the concept itself defies intellectual 
grasp. 

It is sufficient to remember that there are skin conditions which 
seem to be the forerunners of cancer. It is equally important to 
bear in mind that cancer just as often arises from skin which has 
previously appeared normal. The practical point is to be suspicious 
of all neoplasms, regardless of whether they arose upon healthy or 
unhealthy skin, with a certain conservative bias in the direction of 
safety, namely that certain lesions favor malignant evolution. It 
is entirely unnecessary to give such lesions a grotesque and terrifying 
name. All that a scientist needs is to record his experiences in 
his memory in order that he may apply them to the welfare of his 
fellow men. To label experiences, particularly unsoundly, indicates 




Fig. 69. SQUAMOUS CELL EPITHELIOMA 

This lesion is relatively superficial and has a rolled margin, but the 
floor is more vegetative than would be expected in a basal cell growth. 




Fig. 70. EPITHELIOMA. SQUAMOUS CELLED 
TYPE 

Xote the voluminous character of the lesion. 




Fig. 71. RODENT ULCER 

The site, the rolled pearly margin, contour and superficiality of the 
lesion are characteristic. 




Fig. 72. EPITHELIOMA OF TONGUE 

Note the voluminous character of this fungating lesion, and its situa- 
tion at a point opposite the molars. 




Fig. 73. EPITHELIOMA, LIP 

Epithelioma of the lip is less frequent in women than 
in men. This example is typical of the advanced, fun- 
gating' variety. 



THE SO-CALLED PRE-CANCEROUS DERMATOSES 333 

mental limitations to which a true scientist points with anything 
but pride. The so-called precancerous dermatoses are numerous 
and are designated in the ensuing table. Of these nevi, xeroderma, 
Bowen's dermatosis, leucoplacia, horns, lupus vulgaris, Roentgen 
burns and scars are of unquestionable importance. From the rest 
epithelioma undoubtedly arises sometimes. Sailor's skin, arsenic, 
paraffin and soot epitheliomata are well enough known, but ex- 
tremely rare. Dermoid cysts, and for that matter ordinary seba- 
ceous cysts, sometimes give rise to malignancy but this is excep- 
tional. Paget's disease of the nipple has been discussed (Chapter 
XXVIII) and indeed it cannot be stated whether the dermatitis is 
" precancerous " or perhaps secondary to the mammary growth and 
hence postcancerous. Of the conditions enumerated at the opening 
of this paragraph xeroderma pigmentosa, Bowen's dermatosis and 
Roentgen carcinoma form definite pictures. 

Sebokrhoeal Keratomas (Fig. 37) arise in two ways. They 
are either exaggerated seborrhoeal plaques, and hence inflammatory 
in origin; or they are the result of senile regressive skin changes. 
They look like scaly, yellow, brown, buff or dirty gray papules, 
single or multiple and of a diameter rarely exceeding a half inch. 
They arise upon the face, chiefly near the nose or temples, and are 
roughly circular or oval. The scales are adherent, and when re- 
moved leave an oozing surface which first crusts and then scales. 
They may persist with relatively little change for years, and they 
develop from middle age on. It is easy to cure most of them with 10 
percent, to 20 percent, salicyclic acid plaster, and when there is re- 
currence or when they are refractory they readily yield to a single 
X-ray exposure of 4, 6 or 8 Holzknecht units, according to their 
size and thickness. A small proportion of them go on to the forma- 
tion of epitheliomata of either the basal or prickle cell type. It 
might be truer to state that epitheliomata in their early stages clinic- 
ally resemble some seborrhoeal warts, since only very few of these 
lesions ever grow malignant. The practical point to remember is 
that all seborrhoeal keratomas are suspicious and hence should be 
properly treated. 

Leucoplacia Buccalis (Fig. 74) is almost invariably syphilitic. 
At times these lesions give rise to prickle cell epitheliomata. As 
already stated (Chapter XXVIII), although nearly all lingual car- 
cinomata arise from leucoplacial soil, the coefficient of this eventu- 
ality is small. Nevertheless, conservatism demands due suspicion in 
the patient's interest, and the slightest sign of activity in leucoplacia 



334 DERMATOLOGY 

is an indication for imperative measures, as indicated in the pre- 
vious chapter. 

Hokxs of the skin are hyperkeratoses, the origin of which is 
similar to that of ordinary warts. They appear wherever senile 
keratoses may, on the penis, rarely on the trunk and extremities. 
There is a rough similarity to the horns of herbivorous animals, hut 
the growths are short. They may be conical, cornuate, tortuous and 
present a yellow to black furrowed, cracked surface. As a rule they 
do not exceed an inch in length, are situated upon a noninflammatory 
base and may spring from normal skin, a lupus vulgaris scar, sebor- 
rhoeal keratoma, sebaceous cyst, or wart. A very small number 
become malignant. The treatment is excision followed by X-rays 
if evidence of carcinoma is found microscopically. 

Lupus Vulgaris (Fig. 61) is a common disease. Xow and then 
epithelioma arises in the patches or the lupus scars. The ratio is 
unknown, but the fact need cause no astonishment for there is nothing 
in tuberculosis calculated to preclude the development of cancer. 
Thus the inclusion of lupus among precancerous dermatoses seems 
particularly forced. Ulcers and fistulae belong in a similar category, 
and for the same reasons. Inveterate psoriasis and lupus erythe- 
matosus even more rarely terminate in malignancy, and the rela- 
tion to carcinoma of chemical agents such as arsenic, paraffin and 
soot, considering how great is our exposure to them, is strikingly 
remote. 

Dekmoid Cysts and sebaceous cysts rarely are the starting points 
of malignancy, but should be regarded in their potentialities as 
suspicious. Unquestionably scars are often the starting point of 
carcinomas, and particularly the scars of syphilis (lingual, espe- 
cially), lupus and burns of any kind. It must be recalled, how- 
ever, that syphilis aud burn cicatrices are numerous and common, 
and that the development of cancer in them is relatively negligible, 
however great the actual number. Thus their incrimination as pre- 
cancerous is extravagant. Almost, but not quite so far fetched, is 
the sailor's skin cancer. 

In the last two paragraphs a series of conditions has been enumer- 
ated which sometimes precede epithelioma. It is questionable 
whether their relation to malignancy is causal so much as coinci- 
dental. As a mattter of fact they do not give rise to epithelioma 
nearly so often as does apparently normal skin, and if we were to 
be panicky whenever one of the above lesions were observed at the 
cancer age we would do well to subject every individual of forty 



THE SO-CALLED PRE-CANCEROUS DERMATOSES 335 

or over, even with a healthy integument, to a universal exposure 
to eight Holzknecht units of Roentgen rays. With all due respect 
to the terrors of malignancy we must avoid becoming a race of 
hypochondriacs, for carcinomaphobia is no less crazy than any 
other form of insanity. If we wish to be sanely careful let us bound 
our concepts of precancerous dermatoses within reasonable limits, 
rather than extend them to include all the skin diseases that there 
are. We should be careful but remain wholesome. 

The relationship of nevi, Bowen's disease, and Roentgen derma- 
titis to cancer is another matter. Pigmented nevi, as already stated 
(Chapter XXVIII), sometimes become malignant. This is not 
frequent, but melanomata are so serious that all pigmentary moles 
deserve earnest consideration. Only seven cases of Bowen's " pre- 
cancerous dermatoses " have been published. Four were frankly 
malignant. This indicates the inadequacy of the term, but empha- 
sizes the gravity of the disease. The malady occurs anywhere on 
the body, but favors the regions peculiar to seborrhoeal warts, which 
they closely resemble. The lesions are grouped like tubero serpigin- 
ous syphilides, and they slowly progress like these, at times leaving 
an atrophic central scar. Their treatment is that for seborrhoeal 
warts as mentioned above. 

Xeroderma Pigmentosum is an extremely rare familial dis- 
ease characterized by the presence on the exposed skin of dilated 
vessels, freckles, atrophies, warts, keratomas resembling the senile 
variety, and ultimately ulcers and epitheliomata of both varieties. 
Often the cornea and conjunctiva become involved by these growths, 
and usually, with or without them, there is photophobia with lac- 
rimation. The disease begins in infancy, progresses until the 
hands and face or any other exposed areas are involved, and death 
from carcinomatosis supervenes in adolescence or early adult life. 
The diagnosis is easy, the prognosis of course always bad, and the 
disease is extremely rare. Prophylactic treatment consists of min- 
imizing exposure to light, and it does very little good. There is 
no adequate treatment for the fully developed disease. Actually the 
condition is premature senility of the skin. 

Roentgen Carcinoma is a condition formerly more common 
than now, for in later years Roentgen operators have taken proper 
precautions. The general skin reaction produced by the X-rays is 
an artificial xeroderma (Chapter VII) pigmentosum restricted to the 
hands. Telangiecstasia, pigmentation, atrophy, ulceration, hyper- 
keratosis, verrucae and epitheliomata are all present as in xeroderma. 



336 DERMATOLOGY 

In both conditions epitheliomata invariably arise. Thus we have 
in xeroderma, Roentgen dermatitis and sailors skin true precancer- 
ous dermatoses, or better dermatoses some element of which 
eventuate in malignancy. Xeroderma is congenital and precocious 
senility. Eoentgen dermatitis is a regressive process produced by 
X-rays, sailor's skin is partly due to senile regressive changes and 
partly to the actinic solar rays. 




Fig. 74. LEUCOPLACIA BUCCALIS 

Leucoplacia, particularly the syphilitic variety, frequently gives rise to epi- 
thelioma. Leucoplacia resembles lichen planus, but on study, no papules are 
seen, and the white is sheerer than in lichen. 



CHAPTER XXX 

BENIGN CONNECTIVE TISSUE NEOPLASMS 

Although neoplasms of this group have no great clinical or ana- 
tomical similarity they share a common embryological ancestry. It 
is questionable whether at times these growths may not be nevi in 
a sense which will subsequently be discussed (Chapter XXXIII). 
Excepting fibromata and lipomata the conditions are rare, or, if not 
rare, of relatively little significance, and save for the sake of scien- 
tific completeness they would not need to be mentioned. Eibromata 
and lipomata are the common varieties. 

FIBROMA 

Synonyms. Fibroma Durum, Fibroma Molluscum, Molluscum 
Fibrosum, Neurofibroma, Recklinghausen's Disease. 

Definition. A fibroma is a benign new growth formed of fibrous 
connective tissue cells or fibroblasts, the amount of the cells and 
fibrous connective tissue or collagen varying in proportion. At 
times the structure is myxomatous. 

Symptoms. The growths may be single or multiple, present at 
birth or appearing later, and often accompanied by pigmentary 
macules. They are hard or soft, lenticular, sessile or pedunculated 
and they vary in size. Some may be huge and pendulous. They 
are flesh colored, buff, or brownish, and with certain exceptions to 
be stated below cause no subjective symptoms. 

Course. A fibroma practically never goes away by itself. Some- 
times the growths undergo malignant change giving rise to fibro- 
sarcomata or, much more rarely, spindle celled sarcomata. 

Varieties. Some of the varieties have been suggested among the 
synonyms. These are Recklinghausen's (Fig. 75) disease, fibroma 
molle, fibroma durum, myxoma, fibroma pendulum, and keloid, with 
the latter's subvarieties. 

'Recklinghausen's disease or multiple fibromata, or neuro-fibro- 
matosis is not common. It begins in early youth, at puberty or 
rarely in childhood and gradually the body is studded with count- 
less growths, some just visible, others even an inch in diameter. 

337 



338 DERMATOLOGY 

The growths are soft, sessile or pedunculated, at times painful or 
tender and circular or oval. They are flesh colored, brownish, buff 
or red and occasionally traversed by dilated vessels. On pressure 
some are felt to disappear within a ring but pop out again when 
released. At times growths may be felt along nerve trunks. Inter- 
spersed among the above lesions are lentiginous or chloasmic macules. 
and some of the growths are bluish or topped in a manner roughly 
suggesting a vesicle, but containing no fluid. The disease is not 
unlike dermatolysis (Chapter XVII). A low mental and physical 
habitus has been noted, but this is neither constant nor diagnostic. 
The diagnosis is easy, the prognosis good as to life, but the disease 
is irremediable and no rational treatment exists. The cause is un- 
known, but in the broad sense, its origin being embryonal, it may 
be a nevus. Although not rare the condition is uncommon. Some- 
times the fibromata arise upon nerve trunks, as indeed elsewhere in 
the body, but the term neurofibromatosis is thoroughly unjustifiable 
as the tumors lack nerve fibres. 

Fibroma molle not giving the picture of Recklinghausen's disease 
is common. Usually one or two lesions or a dozen are seen. They 
vary in size as above and are. similar in aspect. They are sessile 
or pedunculated, at times hanging by a thread of tissue. Their 
softness is striking. They may be removed by ablation, excision 
or fulguration. These are the lesions also known as fleshy warts, 
and their origin and significance are not known. 

Among the lesions of Recklinghausen's disease and soft fibromata, 
some are found microscopically to be entirely or in part myxoma- 
tous. Clinically such lesions are not distinguishable from their 
fellows, and the myxomatous tissue is probably degenerative. 

Fibroma pendulum is simply an enormous lesion, the size of 
which makes it pendulous. 

Keloids are hard fibromata which are primary or secondary. The 
former arise spontaneously, the latter after trauma such as burns, 
scalds, the accidental or intentional application of caustics, whether 
acid or alkali, vaccination and the like. Primary keloids are com- 
moner in negroes than in whites, and are elevated, hard, linear 
masses, red, white or buff in color, and often crossed by dilated veins. 
They are globular, linear, band shaped, reticular or arborescent and 
their size varies. They favor the sternum, shoulders, neck, face, 
back and extremities. The secondary forms, which are also called 
hypertrophic scars, correspond in general to the spontaneous ones, 
but their shape is determined by that of the original injury, and 



BENIGN CONNECTIVE TISSUE NEOPLASMS 339 

their color is at first bluish, gradually becoming paler. Both types 
tend to recur after excision, and the secondary form often flattens 
of itself. The main difference between keloid and hypertrophic 
scars, as Crocker states, is that the former has no growth limit, while 
the latter never transcends the size and shape of the determining in- 
jury. The best treatment of both kinds is with massive doses of 
X-rays or radium. Excision, ablation, and burning remove the 
growth but it is likely to return. Thiosinamin has been used but 
it is painful and the results are not gratifying. 

Hard Fibromata or fibromata dura are pea sized nodules re- 
sembling the globular or rounded keloids. They are found scat- 
tered upon the trunk or extremities. Structurally they differ from 
soft forms in their greater content of dense collagen. 

Differential Diagnosis. Fibromata of all sorts are easy to 
recognize. In cases of doubt microscopic examination clears up the 
problem. 

Etiology. Nothing is known of the etiology. 

Treatment. This has been described in each condition. 

Prognosis. The prognosis is good as to life. In Reckling- 
hausen's disease little can be accomplished because of the number 
of the lesions. Simple fibromata are easy to cure. Keloids offer 
a bad prognosis because they are prone to recur. 

Neuroma. This condition is closely allied to fibroma. It arises 
as single or numerous tubercles, usually in old men, and the lesions 
appear on the shoulders and arms, thighs and buttocks, as nodules 
or tubercles. They are hard, tender or painful. The tumors ap- 
pear to arise from the sheaths of cutaneous nerves or larger nerves, 
from which they invade the skin. 

Lipomata are fatty tumors arising singly in the breast, buttocks 
and neck, rarely on the face, scalp and genitalia. They are soft 
masses varying greatly in size. At times they are numerous and 
symmetrical and at times painful and associated with general adi- 
posity (Dercum's Disease). They may undergo calcareous degen- 
eration or liquefy, forming cysts, or they may become infected and 
give rise to abscesses. Extirpation is the only therapy. They do 
not recur. 

Osteomata are too rare to mention in detail. They are recog- 
nized by their hardness, and the final diagnosis is microscopic. 

Myoma is a rare skin affection. Muscle tissue is present at times 
in angioma, sarcoma, keloid, and at times in xanthoma as in the 
case of Chambard and Guellano. True myomata, however, are very 



340 DERMATOLOGY 

exceptional. A dartoic variety affecting the nipples, scrotum and 
labia, or independent of these structures, is known. The tumors are 
single or multiple, and although seldom larger than an almond some- 
times attain the size of a fist. They are sessile or have a pedicle. 
The multiple type consists of flat papules whose size rarely exceed 
that of a pea. The lesions are red, buff or brown and translucent. 
They are disseminated and sharply circumscribed, circular or oval, 
and flat, and on palpation they are found to be in the cutis. At 
times they affect only the exterior aspects of the extremities. Often 
they pain severely and paroxysmally. They are composed of striated 
or smooth muscle. Only extirpation is of therapeutic avail. There 
is nothing known of the etiology of the growths. 




Fig. 75. RECKLINGHAUSEN'S DISEASE 

This condition is multiple fibromatosis or perhaps neurofibromatosis. 
The lesions are minute papules or huge tumors, and are interspersed 
with hyperpigmented macules. 



CHAPTEE XXXI 

MALIGNANT CONNECTIVE TISSUE NEOPLASMS 

Definition. Sarcomata are among the rarest skin neoplasms. 
They are composed of mesodermal tissne and consist prevailingly 
of either round, spindle, fibrous connective tissue, lymphatic or 
giant cells, with or without melanin, and with more or less blood 
vessels. At times mixtures of the cells are present, and in general 
their structure is not indicated by their clinical appearance. They 
recur after extirpation, mestastasize to other parts of the skin and 
viscera, and some are highly malignant. The growths are primary 
or secondary. The former are those which arise in the integu- 
ment, — the latter those which, arising elsewhere, invade or are con- 
veyed to the skin, their source being internal organs or a primary 
growth in the skin itself. A peculiar primary form is the nevo- 
sarcoma which is primary as to its sarcomatous character, but sec- 
ondary in that it originates in a preexisting lesion albeit originally 
of a totally different character. Primary growths spring either 
from the cutis or hypoderm and may be single or multiple. 

Symptoms, Course and Varieties. Hypodermic sarcoma 
(Perrin) appears on the trunk, thighs and arms, usually in multiple 
growths. At first the lesions are invisible, but palpable. Later they 
become visible and vary in size from a pin head to a pigeon's egg. 
They are rounded, reddish or violaceous and slightly scaling. They 
are composed of lobulated islands of round cells. The disease is 
most malignant, death occurring from metastasis or inanition within 
a few months to two years. 

There are all sorts of single sarcomata, whitish, reddish, red, 
brown, buff, appearing anywhere on the body and growing, re- 
curring, even metastasizing to other parts of the skin or inner 
organs. They are small nodules at first, gradually reaching the size 
of a pigeon's egg or becoming even larger. They tend at times to 
necrose, rarely to involute spantaneously. Their structure cannot 
be surmised from their gross appearance, for any anatomical type 
may be represented. Of all of these the fibro-sarcomata are the 
least malignant. They may persist and multiply for years doing 

341 



342 DERMATOLOGY 

relatively little harm, but ultimately they, too, cause death through 
inanition or by metastasis. 

Melanotic sarcomata (Fig. 76) arise from nevi in a manner 
analogous to melanoma, anatomically resembling epithelioma. They 
are extremely malignant, having a rapid local growth and throwing 
out metastases. Structurally they resemble round or pigment cell 
sarcomata, with great deposits of melanin. They metastasize rap- 
idly and widely both in the skin and internal organs. 

Secondary sarcomata arise from internal growths and invade the 
entire skin as small or large nodules of lenticular shape, and pos- 
sessing a great play of color. They are hard, rounded and often 
traversed by telangiectasia and possess the structure of the mother 
neoplasm. They kill quickly. Chloromata and hypernephromata 
are of this type. 

Differential Diagnosis. Single lesions resemble sarcoids, granu- 
loma fungoides d'emblee, leucemia cutis, epithelioma, fibroma and 
individual lesions of the various infectious granulomata. The diag- 
nosis can be surmised but not positively established without the 
microscope. 

Ifultiple sarcomata, whether primary or secondary, resemble 
granuloma fungoides as well as fibromatous and the infectious granu- 
lomata. The clinical diagnosis is easy as a rule except with regard 
to granuloma fungoides and leucemia, and, with these exceptions, 
the microscopic diagnosis is always absolute. The clinical differ- 
ences between sarcoma and mycosis lie in the prefungoid derma- 
toses, and the rapid evolution and involution of the lesions. The 
microscopic examination is usually conclusive excepting in so far as 
round celled and lymphosarcoma are concerned. 

It must be remembered that the cell types in sarcoma are, in 
general, more uniform than in granuloma fungoides, that in the 
latter there are more metastases, eosinophiles and giant cells. But 
there is also a giant cell sarcoma to cause confusion, and many 
lesions of granuloma fungoides have uniform round cells. Lympho- 
sarcoma may cause similar confusion. Thus at times the most 
expert clinician or microscopist may, without self-humiliation, feel 
his talents challenged beyond the point of conquest. It is for this 
reason too that many writers are justified in allying mycosis and 
sarcomatosis. Whatever is true of mycosis is also true of leucemia 
versus sarcoma, but the blood picture and other symptoms of leu- 
cemia should aid in diagnostic accuracy. 

Etiology. To attempt to discuss the cause of sarcoma is absurd. 



MALIGNANT CONNECTIVE TISSUE NEOPLASMS 343 

Treatment. Single lesions may be extirpated or X-Eayed with 
success. The use of arsenic and Coley's fluid offers nothing. Mul- 
tiple lesions are at times improved under the X-Rays, but no case of a 
cure is on record. 

Kaposi's sarcoma (fig. 77) 

A special form of sarcoma, Kaposi's multiple hemorrhagic type, 
represents a clean cut clinical picture and thus merits a special place 
in the chapter on sarcoma, It is called benign, but the adjective is 
admissible only in a relative and restricted sense. 

Synonyms. Sarcoma idiopathicum multiplex hemorrhagicum. 

Definition. This disease is a multiple sarcoma, benign in that 
its fatal termination is often long deferred, and characterized by 
multiple growths, widely disseminated, and arising upon skin that 
is pigmented and hemorrhagic. 

Symptoms. The disease begins in the third or fourth decade 
with the appearance of small nodules or tumors, usually on the feet 
or hands. These tumors rest in or under the skin and are flat or 
convex, painless, and rather hard or elastic. Their color is purple, 
red, violet or a deep blue, at times dulled by a grayish superimposed 
filmy color which imparts to the underlying tint a peculiar soft qual- 
ity, such as the peach possesses because of the latter' s delicate fur. 
The skin is often swollen and red, violet or brown, according to the 
character of the hemoglobin derivatives resulting from hemorrhage. 
A few growths may be present, or a great many. At first the lower 
extremities, later the upper, and at times the trunk are involved. 
Edema is provoked to a high degree through lymphatic stasis due 
to occlusion of the lymph vessels by metastases. The palms and soles 
are included. Often, however, only a few blue or purple nodules 
are present. 

Course. As a rule years are required before the disease attains 
its fastigium. Then the entire body or only the extremities may 
be involved with growths as described, or with veritable plaques. 
Some of the growths scale, others involute spontaneously. Still 
others, but only rarely, ulcerate. Whatever the fate of the individual 
lesions the disease as a whole is progressive, and if untreated ter- 
minates fatally, rather from inanition than internal metastasis. 
The patient may die of an intercurrent disease, and the end comes 
within from two to ten years. 

Varieties. There are none except in the degree and rapidity 
with which the disease runs its course. 



344 DERMATOLOGY 

Diagnosis. Kaposi's sarcoma resembles nothing else. Gran- 
uloma fungoides is roughly simulated, but the absence of prefungoid 
lesions and the absence of a tendency to spontaneous involution rules 
out mycosis. Anatomically Kaposi's sarcoma is a spindle cell 
angio-sarcoma with hemorrhage, which differentiates it from any- 
thing else. 

Etiology. Nothing is known of the causation, but it is more com- 
mon in Russian Jews than in any other race. 

Treatment. Arsenic causes relief in some cases. X-rays are 
curative in the early stages, and inhibit progress in the later stages, 
but on the whole no satisfactory therapy is known. 

Prognosis. The disease is usually fatal. 

A concluding word may not be amiss at this point, on the general 
problem of tumor diagnosis. Certain epitheliomata, sarcomata, 
myomata, even fibromata resemble one another clinically. To 
attempt a diagnosis on clinical data alone is often futile. Hypo- 
dermic sarcoma, granuloma fungoides and Kaposi's sarcoma have 
a few points in common. So have these with Recklinghausen's 
disease and myomata. So have some of them, indeed, with lepra, 
syphilis, sarcoid of Darier-Roussey and tuberculous gummata. It 
is unlikely that one would often be confronted with the clinical prob- 
lem of such a differentiation, and yet this might occur. The final 
arbiter is the microscope, for each of the neoplasms has a charac- 
teristic anatomy, and the well trained dematologist must know 
enough of pathological histology to be able at least to distinguish a 
neoplasm from an inflammatory granuloma. To deride the micro- 
scope in its proper sphere is inspired by laziness and ignorance rather 
than by a keen longing for clinical acumen, for it is easier to make 
sport of an unacquired attainment than to master it. Sound clinical 
ability is the most desirable thing in medicine, but there is a broad 
gulf between this and genius at dialectics (a worthless attribute), 
and when a diagnosis can be reached only by microscopic study the 
latter ceases to be an avocation and becomes a duty. Accurate tumor 
diagnosis is possible only by means of histological investigation, and 
is here just as useful, as in the diagnosis of pemphigus it is useless. 
By this means it is possible to determine in five minutes what could 
never otherwise be determined in endless debate, and upon the cor- 
rect diagnosis of tumors depends correct therapy and perhaps the 
only chance for the patient's health — or life. 









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AC 










HLi 


- / ' 7 X- 


«• :K 


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ws 


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H^r. «?• .-.■- --.-. _^ 


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Fig. 76. MELANOMA 

This neoplasm usually starts in a pigmented mole and is brown, black or 
slate-colored. It is highly malignant and breaks down and metestasizes. 



GKOUP IX. NEVI 

A nevus etymologically is a spot or blemish. If its use were not 
restricted in dermatology, about everything could be included. The 
word has acquired limitations, with the passage of time, and now is 
employed as a synonym of birth mark. By no means all ; not more 
indeed, than a substantial minority of nevi are congenital. The 
greater part of them develop within the first year of life. The re- 
mainder appear later. A nevus is a skin lesion due to an embryonal 
tissue disturbance the objective manifestation of which may be pres- 
ent at birth or appear at any time thereafter. 

Several types of this disturbance are generally accepted as nevi, 
others are so regarded by some writers but not by all. A great 
many attempt to restrict the concept to conditions which microscop- 
ically are found to include in their composition the so-called nevus 
cell. This will presently be further discussed. If this were the 
accepted point of view a nevus would have to be defined as a skin 
anomaly, either congenital or appearing after birth, due to an embry- 
onal disturbance, and containing nevus cells. If the broader view 
were accepted, a nevus would have to be defined as any congenital 
anomaly in the skin, present at birth or becoming apparent subse- 
quently. Thus a nevus would depend upon springing from embry- 
onally disturbed cells of any origin whatever, and not solely upon the 
presence of nevus cells. In other words a lesion developing long 
after birth would still be a nevus because it sprang from anlagen 
deposited in intrauterine existence. 

This point of view would appear the more logical, but since it 
is not yet universal it is better to divide the conditions in question 
into two groups, nevi and diseases which are probably nevi. It is 
futile to discuss the origin of these anlagen. Eo one knows whether 
they represent variations or atavisms ; whether they are the result of 
intrauterine trauma or not; or whether they are merely misplaced 
cell inclusions. It is of no practical importance to ponder this ques- 
tion, nor whether nevus cells are invariably epiblastic or mesoblastic. 



345 



CHAPTEK XXXII 

NEVI 

Nevi may be pigmentary, hairy, vascular, lipomatous or hyper- 
trophic; they may be numerous and roughly grouped, or linear in 
distribution. They may be of one or more types, and indeed, a single 
lesion may be composed of several simple forms. The commonest 
combination is the hairy and pigmented nevus. 

NEVUS PIGMENTOSUS 

Synonyms. Pigmented Mole, Nevus Spilus ; French, Tache Pig- 
mentaire, Naevus Pigmentaire; German, Fleckenmaal. 

Definition. Pigmentary nevi are those which have a greater or 
smaller content of melanotic cells otherwise known as melanoblasts 
or chromatophores. They are therefore either light or dark brown, 
blue-black or black, the shade depending upon the amount of pig- 
ment present. 

Symptoms. Nevi of this sort favor the face, neck, trunk, thighs, 
buttocks and genitalia, but they may appear anywhere else. They 
vary in size from minute dots to several inches in diameter, and may 
run the entire scale of colors indicated above. They are circular, 
oval or irregular in outline, flush with, slightly or much higher than 
the skin surface, smooth, corrugated, verrucous, papillamatous or 
cauliflower like, and often hairy (nevus pilosus). Only one lesion 
or many may be present, and they may be grouped when multiple, in 
irregular patches, lines, bands or in a zosterform arrangement. It 
is unusual to find them at birth, but they blossom out in infancy, 
and at puberty some, previously smooth (nevus spilus), become 
raised and irregular. They provoke no subjective symptoms. 

Course. The course has been indicated in the foregoing para- 
graph. These nevi never disappear and when irritated may become 
malignant, the malignancy more often taking the form of epithe- 
lioma than sarcoma. Either type, however, is serious. Irritation 
appears to stimulate them to malignancy, of which the first signs 
are growth, necrosis and a fetid discharge. 

Varieties. Varieties may be determined upon a basis of num- 

346 



NEVI 347 

ber, shape, size and distribution. Such distinctions are artificial. 
Hairy nevi may be regarded as a subvariety of pigmentary ones 
since one practically never sees non-pigmented hairy forms. All of 
the features mentioned are present plus hairs, which may be downy 
or coarse, short or long, sparse or dense, and usually dark. They 
occur anywhere. Such nevi are most disfiguring. They attain, at 
times, huge dimensions covering the cheek or chest, back or buttocks, 
and may be so hairy as to suggest fur. Huge nevi are called giant 
nevi. When linear in grouping the term nevus linearis, or when on 
one side, nevus unius lateris, is applied. 

Differential Diagnosis. The diagnosis is based upon the history 
and appearance of the lesions. Nothing else really resembles nevi, 
but at times pigmentary lesions of other diseases may cause con- 
fusion. In such cases the microscope may be enlisted. The struc- 
ture of the growth is characteristic. Islands of nevus, intermixed 
with pigmentary cells, are seen. 

Etiology. This has been discussed in the opening paragraphs. 

Treatment. Pigmentary nevi should not be removed with caus- 
tics. They should be excised in order to prevent stimulation to 
malignancy. When excision is unfeasible carbon dioxide snow is 
an excellent remedy. Hairy nevi may be similarly treated, or 
if mere electrolytic epilation is practiced this will often in itself 
serve to efface the pigmented elements. 

Prognosis. When undisturbed the lesions are harmless. When 
tampered with, irritated or unskilfully treated malignancy may 
develop. 

VASCULAR NEVI 

Synonyms. Nevus Vasculosus, Nevus Vascularis, Angioma; 
French, Nevus Vasculaire; German, Gefassmal. 

Definition. A vascular nevus is one due to an anomaly of cuta- 
neous vessel formation resulting in their hyperplasia or absence. 

Symptoms. Nevi of vascular origin may be flat or raised, single 
or multiple, small or large, and their color and appearance depend 
greatly upon their structure. They may be present at birth or 
appear shortly thereafter, or small congenital lesions may grow both 
in diameter and depth within the first few weeks of existence. The 
growth may be progressive to a certain point and then cease. Karely 
spontaneous involution is observed, a delicate superficial scar re- 
maining. The shape of the lesions, their shade and distribution 
offer a wide range of possibilities. Any part of the body is their 
site, but the head is the favorite location, particularly near the eyes, 



34S DERMATOLOGY 

root of the nose, oecipito-nuchal area, cheeks, and neck. Crying, 
laughing or straining tend to deepen their color. 

Course. As already stated, the lesions appear at or shortly after 
birth and are capable of limited growth, a very few involuting com- 
pletely. 

Varieties. Varieties are determined partly by appearance and 
partly by structure. The following classification is suggested: 

A. Nevi due to vascular hyperplasia or hypertrophy. 

I. Flat nevi, 

1. Nevus Simplex, 

2. Nevus Flam mens, 

3. Flat Angioma. 
II. Raised Nevi, 

1. Angioma, 

2. Angioma Cavernosum, 

3. Hemangio-lymphangioma, 

4. Angio-lipoma, 

5. Angio Elephantiasis (Virchow). 

B. Ischemic Nevi. 

I. Nevus Anemicus (Vomer). 

Nevus Simplex is seen at the root of the nose, near the occiput 
or finally anywhere else. It is a pale pink to marked red lesion 
from a half inch to two inches in diameter. The borders are rather 
indistinct and formed of feathery telangiectasia. About sixty per- 
cent, of all infants present them, and rather more girl babies than 
boys have them. They tend to fade or disappear in childhood, but 
a great many persist. Their color deepens with effort or crying. 

Nevus Flamsieus is an exaggeration of the above. It favors the 
face, is deep red to purple and occurs in patches from the size of a 
quarter to half the face and neck. The border is short but beyond 
it smaller lesions are seem. Some areas are deep, others superficial. 
Occasionally one sees portions which are raised and have the features 
of angio-lymphangioma or angio elephantiasis (vide infra). Nevus 
fiammeus, also called port wine mark, nevus or stain, and in Ger- 
man, Feuermal, persists through life. 

Flat Angioma occurs as a deep crimson, circumscribed, oval or 
roughly circular spot, or there may be several. The surface is 
lustrous and claret colored. Such nevi bleed easily. 

Raised Axgio^ia has the features of the above, but the surface is 
more or less raised and irregular, or even raspberry like or tabulated. 



NEVI 349 

The lesion bleeds easily, sometimes pulsates, and when near the 
fontanelles may communicate with the cranial sinuses. In middle 
aged persons small cherry red lesions of this type, varying in size 
from a pin head to a cherry stone, are studded over the trunk. 

Angioma Cavernosum is clinically like the preceding form. It 
may reach the size of a walnut or bantam's egg and is often purple 
or blue. 

Hemangio-Lymphangioma has the ordinary features of an angi- 
oma or angioma cavernosum, but feels denser and harder, and the 
blood cannot be easily expressed, for the lymphatics too are involved 
in the hyperplastic process. 

Angiolipoma may have the character of any of the foregoing, 
but the vessels are imbedded in lipomatous tissue. Angio-elephan- 
tiasis is closely related to hemangio-lymphangioma, with the added 
factor of nbromatous masses revealed, upon deep palpation, as hard 
nodules within the growth. This form is chiefly observed in nevi ex- 
tending from the skin through to the mucosa of the cheeks or lips 
or ear lobes, imparting a swollen edematous look to the tissues. 

The color of all of these types is red or blue, or midway between 
these extremes, according to the proportion in which veins, arteries 
and lymphatics enter into the composition of the growth. At times 
vascular and pigmented nevi coexist separately or in the same 
lesion. Anatomically the flat nevi are composed of hyperplastic 
capillaries; the angiomata of hyperplastic and hypertrophic capil- 
laries in the corium; cavernous angiomata consist of hyperplastic 
vessels with a structure resembling that of the corpus cavernosum, 
and situated in the corium and hypoderm. Hemangio-lymphangi- 
omata are composed of hyperplastic and hypertrophic blood and 
lymph vessels; angio-lipomata, of such blood vessels imbedded in 
fat, and angio-elephantiasis of blood and lymph vessels surrounded 
by fibromatous tissue. 

Nevus Anemicus is a curious and rare condition seen chiefly on the 
chest below the clavicles. The lesion consists of a group of pale macules. 
When rubbed the normal skin turns pink or red, the nevus remaining 
sharply blanched. This phenomenon is due either to an absence of super- 
ficial capillaries or a defect in innervation, the vaso dilators being absent 
or the vaso constrictors over active, so that the vessels in the involved 
areas fail to dilate as do those of the normal surrounding skin. 

Differential Diagnosis. There is no difficulty in recognizing 
vascular nevi, Nevus anemicus must be differentiated from leuco- 



350 DERMATOLOGY 

dermas which get pink when rubbed, and from lichen atrophicus, 
white spot disease and morphoea, which are atrophic. Other lesions 
of morphoea, with violet rings, or of lichen atrophicus with lichenous, 
infiltrated margins, are too unlike the pale nevus to cause confusion. 

Etiology. To attempt to elucidate the causation of nevi is 
futile. They are embryonal anomalies and are present at birth or 
are latent for varying periods. 

Treatment. Small vascular nevi are destroyed by electrolysis, 
larger ones with carbon dioxide snow, trichloracetic acid or the high 
frequency spark. Nevus flammeus is best treated with carbon 
dioxide snow, radium or the Kromayer light. Angiomata may be 
excised or treated as outlined in the preceding section. Excision is 
impracticable in very large lesions. Radium or snow are best in 
lymphangioma. There is no cure for nevus anemicus. 

Prognosis. The cosmetic possibilities regarding very large nevi 
are poor, as with any treatment a scar remains corresponding in size 
with that of the original defect, but the scar is white and thus con- 
stitutes a relative improvement. Nevus flammeus gives fairly good 
results when treated with radium or the Kromayer light. 



CHAPTER XXXIII 

DISEASES WHICH ARE PROBABLY NEVI 

There is a number of conditions clinically and histologically 
not closely related, but having the bond of being anomalies. Since 
all growth disturbances are embryonal such diseases may be called 
nevi, unless we desire to restrict this term to lesions containing what 
we call nevus cells. If this is the case the term must be confined to 
narrow usage; if not we must regard all anomalies as nevi. Per- 
haps it would be wiser to make the generic disignation anomalies, of 
which nevi would be a sub class. It makes very little difference 
whether we adopt this point of view, or whether we make nevus 
synonymous with anomaly, so that we standardize our terminology. 
I prefer considering the terms equivalent and the following classi- 
fication would be suggested. 

I. Nevi in the broad sense 

1. Lymphangioma circumscriptum multiplex 

2. Trichoepithelioma 

3. Syringoma 

4. Adenoma Sebaceum 

5. Granulosis Eubra Nasi 

6. Ichthyosis 

7. Monilethrix 

II. Probable members of the nevus group 

1. Keratosis suprafollicularis 

2. Erythroderma congenitale icthyosiforme 
III. Possible members of the nevus group 

1. Xeroderma pigmentosum 

2. Recklinghausen's disease 

3. All neoplasms benign and malignant 

The first group consists of seven members which are obviously 
anomalies of growth. The two members of the second group may 
be inflammatory in origin, but it is more likely they too are anom- 
alies. The third group consists of neoplasms, and it is questionable 
whether Cohnheim's views may or may not be applied to all new 

351 



352 DEKMATOLOGY 

growths. If they may be then all are nevi. On the other hand, the 
neoplastic tendency, equally likely, has nothing to do with embryonal 
disturbances, and in this event there would be no connection with 
nevi. The relation of the third group to nevi must thus still remain 
an open question. 

Lymphangioma Tuberosum Multiplex is rare. The disease 
consists of numerous, small, yellow or orange vesicles containing 
lymph. Each vesicle is as large as a pinhead or lentil and it is 
characteristic for a number of such lesions to group themselves 
closely, while the groups in turn are numerous. The favorite sites 
are the arms, shoulders, scapulae, thighs, axillae and buccal mucosa. 
The disease begins in childhood. Often nevi are associated. It is 
reasonable to regard the condition as a lymph vascular nevus. 

Epithelioma Adenoides Cystic um, or trichoepithelioma papu- 
losum multiplex (Jarisch) (other synonyms are misleading), is an 
anomaly of the hair follicles, as is shown histologically. The disease 
begins at or about puberty and is mainly facial. Symmetrically dis- 
tributed tiny discrete papules arise on the glabella and adjacent 
areas, the temples, cheeks, brow, chin and rarely, the shoulder gir- 
dle, neck, scalp and arms. They are either pearly, yellow or pink, 
and in size never exceed that of a lentil, the average being much 
smaller. Only a few, or a great many, may be present, and they 
feel imbedded within the skin above which they rise a very little. 
A telangiectatic tendency is noted in some lesions, and rarely ulcera- 
tion occurs. After first appearing they increase in number and 
size for a time and then become stationary. Their appearance at 
puberty makes it difficult at first glance to accept the belief that nevi 
are embryonal disturbances. Being hair follicle anomalies their 
expression would obviously not be gained until puberty, when the 
hair develops. The condition most closely resembles milium (Chap- 
ter XXXV) and trichosyringocystoma. Milia can be expressed but 
trichoepithelioma cannot. The differentiation from syringoma will 
be discussed below. Aside from electrolysis or the high frequency 
spark there is no adequate therapy. Thus the prognosis from the 
cosmetic side is poor. 

Syringoma, of which the synonyms are legion, and no name 
for which is exact, is best designated by the characterization at the 
head of this sentence. Some of the other names are hydradenoma 
eruptiva, syringocystadenoma, benign cystic epithelioma, lymph- 
angioma, tuberosum multiplex, syringocystoma, hemangioendotheli- 
oma tuberosum multiplex. The disease is rare and often confused 



DISEASES WHICH AKE PROBABLY NEVI 353 

with trichoepithelioma which it closely resembles when the face is 
involved. Its favorite sites are the trunk from just above the shoul- 
der girdle to pubis, and occasionally the extremities. The lesions 
are the size of trichoepitheliomata, smooth, discrete or grouped, 
soft, yellow, red or brown, and often waxy. Microscopically cysts, 
probably due to a sweat duct anomaly, are seen. These lesions, too, 
appear at about puberty and run a course similar to that of the 
foregoing condition. They are due to embryonally misplaced sweat 
duct cells. There is no adequate therapy save electrolysis or the 
high frequency spark. 

Adenoma Sebaceum (Pringle) is rare. It begins in early child- 
hood as bright red, yellowish or brownish pinhead to lentil sized 
papules on the cheeks, forehead and nasolabial folds. Low men- 
tality has been noted at times. As a rule no alterations in the 
sebaceous glands are noted and Reitmann suggested the name of 
nevus symmetricus facies. Histologically the lesions resemble mi- 
nute fibromata. The treatment is as above. The prognosis is poor. 
At times the condition is associated with Recklinghausen's disease. 

Granulosis Rubra JSTasi (Jadassohn) is extremely rare. The 
tip of the nose is red and covered by tiny, dark red papules. Local 
perspiration is present. The entire picture is a sweating granular 
red tip of the nose. Children from infancy to puberty are affected. 
Although there are histological evidences of inflammation the disease 
is closely allied to hydrocystoma, and it is the probable result of a 
congenital local anomaly of the vasomotor system, causing sweat- 
ing and cystic changes in the coils. This is analogous to the 
vasomotor theory in nevus anemicus (Chapter XXXII). There 
is no satisfactory treatment. 

Icthyosis has been described (Chapter XV). If this and its 
allied conditions are nevi they belong in the hyperkeratotic or 
verrucous group. Keratosis follicularis (Chapter XV) is closely 
related to icthyosis, as is erythroderma congenitale icthyosiforme. 
Xeroderma pigmentosum (Chapter XXIX) and Recklinghausen's 
disease (Chapter XXX) are possibly nevi, but this would depend 
upon further evidence of their being embryonal disturbances. 

If it is admitted that the conditions enumerated in this chapter 
are nevi, these with those included in the preceding one might be 
classified as follows: 



354 DERMATOLOGY 

I. Vascular anomalies 

1. Blood vessels 

a. Hypertrophy or hyperplasia of vessels (see 

'table Chapter XXXII) 

b. Absence of vessels. See nevus anemicus. 

2. Lymph vessels 

a. Lymphangioma circumscriptum 

b. Hemangiolymphangioma 
II. Pigmentary anomalies 

1. Nevus pigmentosum 

2. Congenital absence of pigment 
III. Hair organ anomalies 

1. Nevus spilus 

2. Trichoepithelioma 

3. Monilethrix 

IV. Sweat organ anomalies 

1. Syringoma 
V. Sebaceous organ anomalies 

1. Some forms of adenoma sebaceum 
VT. Anomalies of keratinization 

1. Nevus hypertrophicus or verrucosus 

2. Icthyosis (all forms) 

3. Erythroderma congenitale icthyosiforme 
■i. Keratosis suprafollicularis 

VII. Anomalies of the rete and other epithelial structures 



1. Xeroderma pigmentosum 

2. Epithelioma 

3. Verruca 



In the sense of 

Cohnheim 



VIIL Anomalies of the connective tissue 

1. Angio elephantiasis 

2. Adenoma sebaceum (Pringle) 

3. Eibroma 1 n T ^- rT 
, c }-See comment, group \ II 

4. Sarcoma J ' ° r 

IX. Anomalies of fatty tissue 

1. Angio lipoma (probably vascular) 

2. Lipoma 

X. Anomalies of innervation 

1. Xevus anemicus 

2. Granulosis rubra nasi 






SECTION E. DISEASES OF THE OEGANS OF THE SKIN, 
AND OF THE MUCOUS MEMBKANES 



GKOUP X. THE SKIN AND ADNEXA 
CHAPTER XXXIV 

DISEASES OF THE HAIR AND FOLLICLES 

Diseases of the hair may he grouped as follicular hyperkeratoses, 
dystrophies, infections and nervous diseases. The result of these 
conditions may be an excessive growth of hair or a loss of hair. 
The shaft or follicle or both may be affected. Different hairy 
areas of the body are variously influenced by the conditions. 

A. Hyperkeratoses and inflammation of the follicle. 

I. Seborrhoea (Chapter XI) 
II. Lupus Erythematosus (Chapter XXV) 
III. Folliculitis decalvans 
IV. Trichostasis spinulosa (rare and unimportant) 

B. Dystrophies 

I. Hypertrophies, Hirsuties 
II. Atrophies 

1. Trichonodosis 

2. Fragilitas crinium 
3.i Trichorhexis nodosa 
4. Monilethrix 

III. Pigmentary dystrophies 

1. Canities 

2. Ringed hairs 

C. Infections 

I. Bacterial 

1. Staphylogenic folliculitis (Chapter XXIV) 

2. Folliculitis decalvans 

3. Impetigo of Bockhardt (Chapter XXIV) 
II. Fungi (Chapter XXVI) 

1. Affecting the hair 

a. Trichomycosis 

b. Leptothrix 

c. Piedra 

357 



358 DERMATOLOGY 

2. Affecting the hair follicle (Chapter XXII) 

1. Microsporosis 

2. Tinea 

3. Favus 

III. Pediculosis (Chapter XX) 
D. Xeuroses 

I. Organic 

1. Alopecia areata 

2. Alopecia generalisata 
II. Functional 

Trichotilomania 

Baldness may be primary or secondary. 

A. Primary 

I. Dystrophic 

1. Congenital 

2. Premature 

3. Senile 
II. Nervous 

1. Alopecia areata (Chapter XXXIV) 

2. Alopecia generalisata (Chapter XXXI Y) 

B. Secondary 

I. Traumatic 

1. Injuries 
II. Inflammation 

1. Seborrhoea (Chapter XXV) 

2. Lupus erythematous, ulerythema ophryogenes 

(Chapter XXV) 

3. Folliculitis decalvans, folliculitis staphylogenes, 

Impetigo of Bockhardt (Chapter XXXIV) 

4. The various fungus diseases (Chapter XXVI) 

Regionally hair diseases may differ. 

1. Scalp. All the diseases above enumerated and pediculo- 
sis capitis. 
II. Beard. Mostly staphylogenic diseases, alopecia areata and 
lupus erythematosus, and pediculosis capitis. 
III. Eyebrows. Alopecia areata and ulerythema ophryogenes, 

lupus erythematosus, and pediculosis capitis. 
IV. Eyelashes. Folliculitis staphylogenes, pediculosis pubis. 



DISEASES OF THE HAIR AND FOLLICLES 359 

V. Body. Mostly pediculosis pubis and alopecia generalisata. 

The foregoing tables simply indicate the commonest disturbances 
in the areas under discussion, and are not exhaustive. No great 
emphasis will be laid on any but the more usual diseases. Condi- 
tions already described are so indicated in the first table by the suf- 
fixed chapter numbers. Cross reference is suggested to the student. 
The following descriptions will be limited to diseases not yet dealt 
with. 

FOLLICULITIS DECALVANS (qUINQTJAUd) AND ALOPECIA CICATEISATA 

Synonyms. Pseudopelade, Alopecia Circumscripta, Acne Decal- 
vante. 

Definition. These two, possibly identical, diseases present an 
atrophying folliculitis of the scalp. In Quinquaud's disease a few 
minute pustules are at the margin of the plaques, in pseudopelade 
there is absolutely no suppuration. The disease is, on the whole, 
rare and unimportant, but often resembles other commoner condi- 
tions and must therefore be described. 

Symptoms. Baldness arises in round, angulated, or slightly ir- 
regular patches on the scalp. These patches vary in diameter from 
one-half to two inches and may be single or multiple. Their margins 
are sharp, ending abruptly in a line of normal hair growth. At 
first the bald area is pink, often smooth, sometimes containing fol- 
licles with hyperkeratotic plugs, but totally denuded of all hair. 
As time goes on a wrinkled atrophic skin remains. In folliculitis 
decalvans, near the margin of the patches, where the hairs are seen, 
minute pustules are situated, each pierced by a hair. The two 
processes lead to identical end results. 

Course. The disease runs the course outlined above and ter- 
minates in atrophy with permanent baldness. 

Varieties. Two varieties are known, viz., those described above. 
Their relationship is not universally admitted. 

Differential Diagnosis. Pseudopelade resembles favus, alopecia 
areata lupus erythematous and the alopecia of secondary syphilis. 
Favus is excluded by the absence of spores. Alopecia areata is not 
inflammatory, stumps of hairs are present, and recovery usually 
takes place. In syphilis there are evidences of other secondary 
lesions, and the Wassermann reaction is positive. Lupus erythema- 
tosus cannot be excluded and, indeed, many writers consider the 
processes identical, but absence of hyperkeratosis, marked plugs and 



60 DERMATOLOGY 



absent signs of lupus erythematosus elsewhere exclude the latter. 
Folliculitis decalvans is differentiated from all of the preceding, 
and along the lines mentioned, but impetigo of Bockhardt, staphy- 
logenic folliculitis and pustular ringworm must also be excluded. 
The first two resemble folliculitis decalvans in the character of the 
pustules, but the latter are more numerous and larger. Neverthe- 
less it is to be remembered that some writers consider folliculitis 
decalvans identical with staphylococcus folliculitis and impetigo of 
Bockhardt, so that it is impossible to state precisely where this 
disease belongs. In ulerythema sycosiforme, which is merely a sub- 
variant of staphylogenic folliculitis or sycosis of the beard, an 
atrophy remains very similar to that of folliculitis decalvans, so 
that after all the latter may very well be closely akin to Bock- 
hardt's impetigo which is conceded to be only staphylogenic follic- 
ulitis of the scalp. 

Etiology. Pseudopelade is either related to lupus erythematous 
or staphylogenic folliculitis. In the former event its etiology would 
be that of the related disease (Chapter XXV). In the latter event 
it would be the staphylococcus (Chapter XXIV). The same is true 
of folliculitis decalvans, the precipitating factor of which is the 
staphylococcus. 

Treatment. This is parallel to that of lupus erythematosus 
and staphylogenic folliculitis. Since, however, the end result 
of the malady is atrophy and alopecia, cosmetic cures are impos- 
sible. 

Prognosis. As a corollary to the preceding, the prognosis is 
poor. 

HIBSUTIES 

Hypertrophy of the hair, hypertrichosis, superfluous hair, etc., as 
its name implies is a condition in which an excess growth of hair 
is present where it should not be, or one in which the hair grows with 
unusual vigor. It may be general or partial and present at birth 
or appear later. In some instances, such as dog-faced men, or in 
women with hirsutes the condition, always pathological, has practical 
significance. In suitable cases the only treatment is removal by 
electrolysis. Women are often depressed or even become melancholy 
from the defect. Certain cases may be ascribed to pituitary de- 
ficiency and suitable gland therapy is said to cure the condition. 
The use of depilatories is to be condemned. A razor is better. The 
common superstition that soap or grease augment or cause hirsutes, 
is one of which women should be disabused. 



DISEASES OF THE HAIR AND FOLLICLES 361 

Eragilitis Crinium indicates increased breakability of the hair. This 
may occur by splitting of the ends, fractures in the shaft, or either, in or 
above the follicle. Hot air drying, lack of grease, etc., are supposed to cause 
the condition which can in part be remedied by the use of oils and creams. 

Trichorhexis Nodosa is a condition seen chiefly in the beard. The 
disease consists of ravelling of the hair, at node like points, causing monili- 
form projections found to consist of the disintegrated strands. The hair 
is seen to be studded at regular intervals with swellings at the sites of 
which the shaft easily breaks. The cause is unknown and there is no 
adequate treatment. 

Trichonodosis. A similar appearance exists in trichonodosis, but the 
nodes are due to the spontaneous knotting of the frayed hair. 

Monilethrix is a family disease seen mainly in women. It occurs 
chiefly over the occiput, but may be found elsewhere. The hair shaft is 
alternately constricted and swollen so that it resembles a chain of minute 
beads. MacKee ascribes the disease to a congenital anomaly of the follicle. 

'None of these conditions is curable or of great practical impor- 
tance. To all of them is applied the generic term of atrophia 
pilorum propria. 

Pigmentary disturbances of the hair take the form of patches of 
hair of different colors, ringed hair, or canites. In ringed hairs al- 
ternate bands of white and pigmentation are seen. Canites is white- 
ness of the hair. It normally appears in the prime of life or at the 
onset of old age. It may appear prematurely. It may be partial 
or complete. Its only cure lies in the use of dyes. 

ALOPECIA AREATA (FIG. 78) 

Synonyms. Area Celsi, Alopecia Areolaris, Pelade. 

Definition. Alopecia areata is characterized by the sudden loss 
of hair in slightly inflamed disc like surfaces, which may be single or 
multiple. The disease tends to recur. 

Symptoms. The disease begins suddenly with the appearance of 
bald spots. These are usually circular, oval, or irregular, and single 
or multiple, varying in size from one-half an inch to two inches in 
diameter. The denuded surface is lax, white and shows patulous 
hair follicles. Here and there a hair stump one-fourth of an inch 
or so long, and shaped like an exclamation point, is seen. The peri- 
phery of the patch abuts sharply against the normal hair. ]STo sub- 
jective symptoms are noted. The scalp, beard and, at times, the 
body are affected. 

Course. After a few weeks or months the denuded area is cov- 
ered with fine hair which in a year or two is normal. At first the 
hair is often white, resuming its proper tinge gradually if ever. At 



362 DERMATOLOGY 

times the hair never returns, or at times only partially. Recur- 
rences are common. 

Varieties. In youth asymmetrical patches are usually observed, 
in middle age symmetrical ones. At times baldness appears in a 
band from the occiput to above the ears. This band is an inch broad, 
and this form of the disease is restricted to children. Otherwise it 
closely resembles alopecia areata. At times the eyebrows, mous- 
tache or lashes are the site of pelade. A generalized form of 
alopecia areata (the name is a contradiction of terms) is seen. 
Alopecia generalisata causes total loss of hair. 

Differential Diagnosis. Alopecia areata must be differentiated 
from ringworm, favus, pseudopelade, lupus erythematosus, follicu- 
litis decalvans and all other types of baldness. 

A patch of alopecia areata is sharply circumscribed, the skin is 
lax, dead white and contains a few exclamation point hairs. At the 
periphery the apparently unaffected hair is easily withdrawn. ~No 
atrophy exists. In pseudopelade, lupus erythematosus and follicu- 
litis decalvans, atrophy exists, and the other evidences of alopecia 
areata are lacking. In favus there is atrophy, and in this disease, 
as well as in ringworm, there are scales, fragile hairs and spores 
which are microscopically demonstrable. In all other forms of bald- 
ness the signs already mentioned of alopecia areata are lacking. 

Etiology. Alopecia areata is commonly considered a nervous dis- 
turbance. So far as can be judged by circumstantial evidence this 
appears to be likely. All efforts to prove it the result of a local or 
general infection have failed. Undoubtedly the effects of shock, 
emotional strain, and the like, are responsible in some instances. In 
the majority, however, no such cause is ascertainable, nor is there 
any ground to assume ill health or a neuropathic habitus. 

Treatment. The affected surface should be painted every five to 
seven days with pure phenol which is immediately neutralized with 
absolute alcohol, or the patient may be given equal parts methyl 
salicylate in chloroform to apply daily. Capsicum and cantharides 
lotions are also valuable. So is the Kromayer light. In the 
author's experience the first two methods have afforded the best 
results. Favorable cases are self limited, but with suitable treat- 
ment the course can be shortened. In unfavorable cases no known 
therapy is of avail. When the new hair remains white, dyes may 
be used. 

Prognosis. Asymmetrical forms in the young have a favorable 




Fig. 78. ALOPECIA AKEATA 

This condition, also known as pelade, occurs as one or 
patches which by coalescence, give the picture here 
usually return and mav be white 



more circular, bald 
shown. The hairs 



DISEASES OF THE HAIK AND FOLLICLES 363 

prognosis. Symmetrical cases in the middle aged and old have not. 
In many instances recurrences take place. 

A word as to baldness in general. The forms of baldness have 
been tabulated early in this chapter and the terms are self-explana- 
tory. Cross reference to the respective underlying diseases will 
disclose both causes and therapy. Traumatic forms are due to 
scars following injury or disease, as furuncles, cuts, burns and the 
like. 



CHAPTER XXXV 

SEBACEOUS DISEASES 

This group of conditions represents disturbances of the sebaceous 
glands determined by excessive function. This in turn is the cause 
or effect of hyperkeratosis of the follicles, as the case may be; and 
subject to circumstances, inflammations or mechanical abnormali- 
ties, or both, arise. 

Seborrhoea of the psoriasiform type has been described among 
the psoriasiform dermatoses (Chapter XI) and seborrhoeal derma- 
titis has been mentioned among the vesicular diseases (Chapter IX). 
Whether these are primarily seborrhoeal in the etymological sense is 
debatable. That group of conditions about to be described is defi- 
nitely restricted to morbidity of the sebaceous glands and it includes 
five entities, i. e. acne, sebaceous cysts, milium, dermatitis papillaris 
capillitii and rosacea. The first four have close bonds. 

Acne is a corruption of the Greek word acme meaning a point. 
Accordingly the term has been widely employed in other senses than 
the one to which we apply it restrictedly. Among these are acne 
artificialis, caused by tar, iodides and bromides ; acne cachecticorum, 
due to tuberculosis ; acne urticata, a form of chronic urticaria ; and 
acne keratosa, a rare disease. Here we shall deal only with sim- 
ple acne. 

ACNE 

Synonyms. Pimples, Acne Vulgaris, Varus ; French, Acne ; Ger- 
man, Hautfinne. 

Definition. Acne vulgaris is a chronic disease of the sebaceous 
glands, characterized by an occlusion of their apertures with a 
greasy, horny plug, and an associated suppuration of the periglandu- 
lar tissue. 

Symptoms. The disease begins at or about puberty with the 
gradual development of plugs in the sebaceous follicles. These plugs 
are called comedones and they are black at the skin surface, above 
which they just perceptibly project. When expressed they are found 
to vary in appearance. Some are hard elongated casts of the hair 
follicle above the level of the sebaceous emunctory. These are a 

364 



SEBACEOUS DISEASES 365 

millimeter or two long, gray and waxy. Others are tKe size and 
shape of millet seeds. Others have a black tip, but when expressed 
come out in a curled vermiform shape, as oil paint emerges from 
a tube. At times they are combined, the first part expressed re- 
sembling the first variety, the second part, the second. Some are 
hard to express, others easy. At times two follicles unite and con- 
tain a single comedone with two heads. These are called bridge 
comedones. Huge comedones, an eighth inch in diameter, are some- 
times seen, and these are known as giant comedones. 

The sites affected are the forehead, temples, nose, chin, ears, an- 
gles of the jaws, chest and back. Any part of the face may be 
involved and often the shaft of the penis, scrotum and pubis are 
also. Thus the affected skin is studded with minute black points, 
and a sensation of roughness is imparted to the palpating finger. 
These plugs dam back the sebaceous secretion to such an extent that, 
in extreme cases, the sebaceous gland becomes prominent because it 
is choked with its own product. In this picture a pearly papule is 
present surmounted by a black dot. In other words many minute 
sebaceous cysts are formed. The mechanism of the process is a 
hyperkeratosis of the follicle mouth. The exfoliated cells are not 
extruded and become saturated with sebum. The surface portion 
turns black because it contains substances reducible by oxygen. 
When the hyperkeratosis is so situated that it cuts the comedone off 
from the air no oxidation occurs. Hence no black dot forms, but a 
comedone is present, as expression will prove. When minute cyst 
formation occurs white seed-like dots appear, particularly on the 
cheeks and temples. These are milia. They are chalky in color, 
inexpressible, and when removed by curetting off the surface cuticle, 
a small glistening spherical mass may be pressed out. 

The skin in the involved areas is usually oily, more or less 
muddy and thick. Either the disease remains limited to the come- 
done stage, in which a lustreless complexion is seen, studded with 
black dots; or suppuration sets in. The abscesses or acne pustules 
vary in size from minute dimensions to a diameter of half an inch. 
At first a papule arises, in the centre of which is usually observed 
a comedone. Gradually pointing develops, then fluctuation. The 
abscess bursts, crusts and heals, leaving a red spot which very gradu- 
ally fades. On expression a drop of pus and a comedone come out. 
The life history of a pustule is from four to ten days. If the papu- 
lar stage persists the condition is called acne indurata, when there is 
great induration. Otherwise it is called acne papulosa. Acne punc- 



366 DERMATOLOGY 

tata is the designation for the condition when numerous minute 
pustules are seen. The color of the pustules and papules ranges from 
pink to purple. At times deep cutaneous abscesses are intermingled 
with the pustules. The pustules, comedones, dull skin and oiliness, 
together form a varied picture. 

When the process is over, the skin remains somewhat thickened, 
the follicles are patulous, and numerous pocklike scars are seen, so 
that the smoothness of the integument is lost. Coincident with 
acne one often finds seborrhoea of the scalp, furunculosis, and a 
peculiar, fine, pale line just under the vermilion border of the lower 
lip, and a brownish discoloration of the chin and temples. The 
pustules often come in crops particularly in relation to the menses ; 
and in men, at times, in relation to coitus. Often hyperglycemia, 
anemia, acid stoods, gastric hyperacidity, and starch indigestion are 
associated. 

Course. The disease starts at or about puberty and lasts as a 
rule well into the third decade, but it may end sooner or later, 
rarely persisting until thirty-five or forty. 

Varieties. The varieties of acne vulgaris have been included in 
the symptomatology. These are purely artificial and are senseless 
distinctions. Neither is there any justification for distinguishing 
comedones from acne so far as the underlying cause is concerned. 

Differential Diagnosis. Acne differs from staphylococcus fol- 
liculitis in that in the latter the pustules are pierced by hairs, and 
no comedones are present. Bromide and iodide acne are also dis- 
tinguished by absence of comedones, but bromides and iodides may 
cause an eruption in people suffering with acne vulgaris, and in this 
event only the history will facilitate the diagnosis. Miliary lupus 
and acne necrotica are also recognized by the character of the lesions 
and absence of comedones. The positive signs of acne vulgaris are 
the comedones, pustules and the age at which the disease occurs. 

Etiology. The etiology of acne vulgaris represents a wide field 
for speculation. Before going into details it may be well to recall 
some of the broader features of the malady. It is a condition aris- 
ing at or about puberty, tending to spontaneous termination at the 
end of adolescence. It is often increased in severity at the menses, 
or in males after coitus. These facts strongly suggest its rela- 
tionship to metabolic changes peculiar to the period of maturing. 
In the last analysis this indicates dependence upon endocrinous 
gland alterations. Such evidence is significant but of course only 
circumstantial. 



SEBACEOUS DISEASES 367 

Further elements in the causation of acne may be divided into two 
groups, internal and external. The internal causes are digestive and 
evidently sexual. Thus constipation, carbohydrate indigestion and 
fermentation, gastric hyperacidity, and even gastric ulcer may be 
found associated with acne. Excessive ingestion of sugars and 
starch alone, often exaggerate attacks. Allied with acne, hyper- 
glycemia is fairly constant. It may be alimentary or perhaps de- 
pending upon hyperthyroidism, a frequent feature of puberty. The 
sexual elements in its causation are indicated by the influence of 
menstruation and coitus. 

The external causes are irritation and bacteria. In one sense this 
statement is untrue. Acne is obviously a disease of hyperkeratini- 
zation, and sebaceous hypersecretion, inasmuch as the cuticle forms 
excessively and the glands secrete excessively, producing a mass of 
greasy scales which fill the follicles. This mass acts as a foreign 
body and suppuration takes place. To all intents and purposes the 
disease is present when comedones form. Suppuration is a super- 
added feature depending upon irritation and pathogenic bacteria of 
many varieties; staphylococci, bottle or acne bacilli, related to the 
Friedlander group. The pathogenicity of the latter group is by no 
means proved. 

Massage, rough handling of the skin with coarse towels, unskil- 
ful expression of comedones and pustules, all make the disease worse, 
and often convert a simple pustule into a persistent papule or slug- 
gish abscess or furuncle. 

Treatment. The indications are clear. A test meal indicates 
the special digestive regimen to be followed. In general a diet de- 
signed to overcome constipation, lessen hyperacidity, and diminish 
the starch intake should be prescribed. Such medication as cathar- 
tics, antacids, digestive enzymes should be added as indications 
arise. Surgical conditions predisposing to the above should receive 
their special operative relief. Gynecological disturbances supply 
their particular indications. Obviously in weak, undernourished, 
atonic or asthenic individuals suitable methods of life should be pre- 
scribed, but this all constitutes a generalization applicable to all ill- 
ness and requires no further emphasis. Arsenic is of no use in 
acne; neither is calcium sulphide, and in fact most tonics and 
alteratives are of little service outside of the imagination. 

The local indications for treatment are twofold: first, to prevent 
hyperkeratosis of the follicles and hypersecretion of the sebaceous 
glands; and, second, to cure the condition if already established, as 



368 DERMATOLOGY 

well as to cure pustulation. The prophylactic treatment consists 
in the use of Roentgen rays, one Holzknecht unit weekly to a given 
area, which overcome exfoliation and hypersecretion. Medicaments 
also serve this purpose. Sulphur, resorcin, or salicylic acid lotions 
applied every night, after washing gently with soap and hot water, 
are the best methods. The following are types of these lotions : 

T$ Potass, sulphurat. 

Zinci sulphat aa 6.0 to 10.0 

Aquae Rosarum qs. ad 100.0 

Sig. 
3J R^sorcini . . . 3.0-5.0 or acidi salycilici 2.0 

Glycerini 5.0 

Alcoholis q.s. ad 100.0 

Sig. 

The first should be shaken thoroughly before applying. When 
resorcin is employed, the patient should be warned as to his eyes, 
for resorcin may cause conjunctivitis. These preparations cause 
exfoliation which favors the emptying of follicles and pustules, a 
mechanical task to be done by the physician, with proper comedone 
extractors. Vaccines have been of little value so far as the author's 
experience goes. 

Prognosis. The majority of cases of acne are curable, but at 
times the utmost persistance is needed. The cosmetic result depends 
upon the type of the pustules which, when large, leave permanent 
scars. 

Milium is a disease which may occur at any site involved in acne. 
The lesions are minute, white semiglobules. They may be sparse 
or numerous and can be cured only by removal with a sharp scalpel 
or bistoury. They are essentially tiny sebaceous cysts, and are 
seen chiefly near the eyelids and on the cheeks. 

Sebaceous Cysts, wens, atheromas, or steatomas occur also at 
the sites favored by acne. They are deep seated tumors with a 
black point (comedone) at the site of which they are attached to 
the cutis, elsewhere being free. They are moveable at all points 
but the one mentioned. They may be infected and become abscesses, 
or rarely undergo malignant alteration giving rise to epithelioma. 
Their treatment is surgical. When infected they are to be man- 
aged as any abscess. As non-infected, growing cysts they must be 
carefully dissected out. 

Dermatitis Papillaris Capillitii, also called acne keloid, and 
dermatitis sclerotisans nuchae, is a disease in males, and located 



SEBACEOUS DISEASES 369 

over the back of the neck from about the collar line to the occiput. 
The clinical picture consists of pustules, comedones, and broken off 
stubbly hairs emerging singly or in brushes from patulous follicles. 
The feature giving the disease its name is the presence of hyper- 
trophic or pseudokeloidal cicatrices at the site of former pustules. 
These in turn further predispose to distorted follicles, occlusion 
cysts and comedones which suppurate. The only efficacious therapy 
lies in the employment of Koentgen rays. In certain cases elec- 
trolysis and local treatment, as in acne, avail. 

ROSACEA (FIG. 79) 

Synonyms. Acne Rosacea; French, Couperose; German, Kup- 
ferrose. 

Definition. Rosacea is a chronic disease of the face depending 
upon vascular dilatation with the formation of telangiectasia. As 
the result of hypernutrition of the sebaceous glands the skin is oily, 
comedones form, often with pustulation, and there is a marked 
tendency to hyperplasia of the pilosebaceous follicles and connective 
tissues. 

Symptoms. At first the face flushes easily upon exertion, irri- 
tation, exposure to extremes of climate and the ingestion of hot or 
highly seasoned food. Gradually the vessels dilate, telangiectasia 
and blotches forming, and the skin grows oily. The disease has its 
ups and downs, at times disappearing entirely, then after a dietetic 
indiscretion, after an attack of dyspepsia, with the menses or at the 
menopause, it gets worse. At times the patient complains of a 
sensation of facial heat. The onset of the disease occurs in adoles- 
cence or in the third or fourth decade. 

After persisting in the stages mentioned for months or years, the 
flush becomes permanent, many vascular blotches or coarsely dilated 
veins are seen, papules and pustules develop and the skin is oilier. 
Admixed with this picture is that of acne. Still later hypertrophy 
of the cutis causes fibromatous masses, particularly on the nose. 
This provokes a grotesque swelling that may increase the dimensions 
of the organ three- to five-fold. This is rhinophyma, and the nose is 
a huge, red or purple fibromatous mass, cribriform with patulous fol- 
licles containing inspissated sebum, traversed by engorged red or 
purple vessels and covered with pustules and papules. 

The sites involved in the process are the nose, chin, cheeks and 
temples. In the picture one discerns a composite of scaly and oily 
seborrhoea and telangiectasia, acne vulgaris and connective tissue 



370 DERMATOLOGY 

hypertrophy. Usually there is an associated gastric or pelvic mal- 
ady. In fact these probably bear an etiological relationship to the 
disease. 

Course. The disease is eminently chronic, beginning in adoles- 
cence or adult life and following a course of years. It may be 
arrested and remain stationary in its earlier stages, or continue to 
rhinophyma or to similar hypertrophy elsewhere than on the nose. 

Diagnosis. Only lupus erythematosus discoides is simulated. 
In this condition there is scaling and atrophy, however, and no 
pustules are seen. Thus confusion can arise only during the early 
stages of rosacea, and here it is possible to exclude error only through 
observation. 

Etiology. Aside from the fact that puberty plays no role in the 
causation of rosacea the etiology of the disease is identical with that 
of acne vulgaris. On the other hand the menopause certainly is the 
starting point of many cases. More specifically alcoholism, constipa- 
tion, gastritis, the use of spicy, over-hot foods all play a distinct 
causative role. 

Treatment. The general and local treatment are as in acne 
vulgaris. X-rays are harmful however. Scarification of the face is 
useful. Proper treatment of the digestive tract, as suggested by a 
consideration of the etiology, often works wonders. Rhinophyma 
responds only to surgical treatment. The patient is anesthetized, 
and the redundant tissue ablated and covered with a tight dry 
dressing. 

Prognosis. Many early cases may be arrested by proper general 
and local treatment. Many late cases can be improved, and a few 
cured. A large number in all stages are obstinate. 




Fig. 79. ROSACEA 

At first, the face flushes, then the vessels are 
permanently dilated and pustules form. The nose 
may hypertrophy, giving the picture of rhino- 
phyma. 



CHAPTEK XXXVI 

DISEASES OF THE SWEAT APPARATUS 

Diseases of the sweat apparatus are secretory and organic. 

I. Secretory Disturbances 

1. Disturbances of amount of secretion 

A. Excessive secretion, hyperhidrosis 

B. Diminished secretion, or hypohidrosis 

C. Absence of secretion, or anhidrosis 

2. Disturbances of character of sweat 

A. Colored sweat or chromidrosis 

B. Malodorus sweat or bromidrosis 

C. Sweat containing abnormal substances, as 

(a) uridrosis 

(b) phosphoridrosis 

(c) hematidrosis 
II. Organic Disturbances 

1. Inflammatory 

A. Sudamina 

B. Miliaria rubra 

C. Miliary fever 

D. Pompholyx 

2. Infectious, staphylogenic infections of the sweat glands 

or hydradenitis suppurativa staphylogenes 

3. ISTevi 

A. Granulosis Rubra Nasi 

B. Syringocystoma 

4. Unclassified. Hydrocystoma 

Thus it will be seen from the above table that diseases of this sys- 
tem are neither numerous nor important. Indeed the majority of 
them are rare. The practical student of dermatology need bestow no 
more than a passing regard upon the subject. 

Hypegbhidrosis, called hydrosis and by several other names, is 
an increased flow of sweat. It may be local, general, transitory or 
chronic, and slight or marked. It is physiological or pathological. 
Some people perspire more than others. Likewise some body areas 

371 



372 DERMATOLOGY 

are moister than others, as the armpits, groins, perineum, palms, soles 
and spaces between the fingers and toes. The gradations from the 
normal to abnormal are difficult to trace. Cold weather inhibits 
perspiration. Emotional strain and excitement increase it. The 
flow may be so great as to cause drops to form on the skin even in 
cold weather. The disadvantages of excessive sweat flow are obvious. 
Localized hyperhidrosis, symmetrical or asymmetrical, sweating of 
the nose, forehead or chin are occasionally seen. Spicy foods cause 
hyperhidrosis in some people, excitement does so in others. Drugs 
such as salicylates, quinine and pilocarpine are sudorifics. 

Tuberculosis causes the well known sweats. The end of severe 
fevers as in malaria, pneumonia, typhoid, are attended by perspira- 
tion. In cachexia of any origin sweats are common. This is also 
true in certain central and peripheral nervous maladies. The pre- 
cise mechanism in these processes is not understood. Thus etiologi- 
cally there is very little to be stated. 

There is very little to be accomplished therapeutically. Atropin 
is the only rational drug and this is of little value because the condi- 
tion recurs when the drug is stopped. Various local remedies, pow- 
ders, lotions and the like, are employed. Their number testifies to 
their inefficiency. Perhaps weak formalin, five percent, in alcohol, 
and salicylated powders do most good. The former is unpleasant 
and prone to cause dermatitis. Furthermore the damming back of 
the secretion predisposes to furunculosis. Diachylon ointment is of 
some value. Roentgen rays, in a dose of one Holzknecht unit, 
weekly, for ten or twelve exposures, causes partial atrophy of the 
coil glands. This is of most value. The prognosis is bad. 

Anhidrosis and Hypohidrosis are rare conditions. Their char- 
acteristics and symptoms are obvious. People with psoriasis, ichthy- 
osis, and nephritis are prone to the condition. Pilocarpine is the 
only useful drug but it is dangerous. A practical point is to note 
that anhidrosis predisposes to sun and heat stroke. 

Chromidrosis is rare. The sweat is colored blue, brown or yel- 
low and each form is suitably named. The pigments are phosphorus, 
hemoglobin derivatives, indican, cyanogen, etc. Trichomycosis pal- 
mellina causes red sweat, and there is also a black sweat. ISTo valu- 
able therapy is known. 

Uridrosis is due to urea in the sweat. Phosphoexdrosis is oc- 
casionally seen in cachexias. Hematidrosis is seen in the hem- 
orrhagic diseases. All are unimportant. 

Bromidrosis or malodorous sweat is usually allied with hyper- 



DISEASES OF THE SWEAT APPARATUS 373 

hidrosis. Any site may be affected. Various drugs, foods and dis- 
eases cause it in a passing form. The odor is most offensive and 
the treatment is that of hyperhidrosis. 

Stjdamiwa or miliaria crystallina is a condition in which, because 
of occlusion of the pores, the sweat is temporarily dammed back so 
that a sweat cyst is formed. The cysts are crystalline vesicles. As 
a rule the torso is involved, and is studded with lesions resembling 
tiny limpid dew drops. They are very delicate structures, the ob- 
struction being but a few layers of horny cells easily removed, so that 
in bathing they vanish. This fact indicates the proper treatment. 
After the bath talcum powder is used. Excessive sweating whether 
due to exercise, heat or fever, causes the rash, the predisposition to 
which is twofold, overacting glands and hyperkeratosis. 

Miliaria rubra, lichen tropicus, prickly heat, is a vesiculo papular 
disease frequently observed in hot weather. Itching or burning 
accompany it. The same factors and significance are peculiar to it 
as to the preceding condition. It differs from the latter in that it 
is inflammatory. It is peculiar to infants and children, but also 
afflicts adults. At times it predisposes to dermatitis and, in the 
adipose, to intertrigo. It is cured by bathing and powdering. 

Miliary fever, is a rare exanthem, if it is indeed, a clinical entity, 
and requires no further mention. 

Pompholyx has already been described (Chapter IX). Infec- 
tions of the sweat glands are included in furunculosis (Chapter 
XXIV). Granulosis rubra nasi and syringocystoma have been 
dealt with among conditions probably nevi (Chapter XXXIII). 

Hydro cystoma is a papulo vesicular disease of the face seen in 
middle aged women. It is not known whether it is inflammatory or 
not. At any rate the coil glands are converted into transitory cysts. 
Thus the lesions are deep seated. They are white or bluish papules 
containing a neutral or faintly acid fluid, and are the size of millet 
seeds. The face perspires easily and the sites involved are the fore- 
head, cheeks and nose. Kitchen and laundry work are etiological 
factors. To cure the condition the predisposing cause must be 
eliminated, the cysts punctured, and a weak salicylated alcohol ap- 
plied several times daily. 



CHAPTER XXXVII 

DISEASES OF THE NAILS 

Disturbances of the nails are congenital or acquired. Congenitally 
the nails may be absent (anonychia) or nails may be abnormal in 
that they participate in such anomalies as supernumerary, fused or 
wrongly implanted fingers or toes. These conditions are rare and 
unimportant. Acquired disturbances of the nails are numerous and 
the following classification is suggested: 

I. Anomalies 

1. Hypertrophies 

a. Onychauxis 

b. Pterygium 

2. Atrophies 

a. Onychatrophia 

b. Hapalonychia 

c. Koilonychia 

d. Onycholysis 

e. Onychomadesis 

f. Leuconychia 

g. Onychorhexis 
h. Furrows 

II. Dystrophies (due to disease) 

1. Systemic 

a. Syphilis 

b. Tuberculosis 

c. Acute fevers 

d. Cachexias 

2. Local 

a. Psoriasis 

b. Dermatitis 

c. Erythrodermas, etc. 

III. Inflammations of the nail bed 

1. Onychia and onychia maligna 

2. Paronychia 

3. Ingrown nail 

374 



DISEASES OF THE NAILS 375 

IV. Injuries 

1. Hangnails 

2. Subungual hemorrhage 

3. Traumatic furrowing 

V. Tumors 

1. Subungual 

2. Nail bed 

VI. Infections 

1. Bacterial 

a. Pyogenic 

b. Tubercle bacillus (Tuberculosis verrucosa cutis) 

2. Fungus 

a. Trichophytosis 

b. Favus 

C. Blastomycosis, sporotrichosis, etc. 

3. Syphilis 

Onychauxis or hypertrophy of the nails, also called onychogry- 
phosis, may involve the nails in any combination from one to more, 
even including all the digits. Thus the nails may be thickened, 
lengthened, distorted and discolored. They are yellow, brown or 
black, hard or friable, and look like lustreless claws or talons. The 
surface is rough or rigid, and below the nail is a hyperkeratotic plug. 
Trauma, pressure, neglect, filth or systemic disease such as lepra may 
produce the condition, for which no cure exists. 

Pterygium is a disease of the fold covering the base of the nail. 
The fold hypertrophies and covers the nail. 

Onychatrophia is an atrophy of the nails, congenital or acquired through 
disease. The nail is defective, thin, breaks easily either longitudinally or 
transversely, is lusterless and ridged. In hapalonychia the nails are thin 
and brittle. Koilonychia is a dystrophy in which the dorsal surface of the 
thin nail is concave instead of convex. Onychonychia or onycholysis is a 
condition in which the nail easily separates from its bed. Onychomadesis 
is a condition in which the nail easily falls off. These are all due to 
systemic or trophic diseases. In leuconychia white spots form on the 
nails. In onychorhexis the nails split longitudinally, the split starting in 
longitudinal furrows or fhitings. Transverse furrows are the result of 
injury /from manicuring, local or general diseases, and are often transitory. 
The treatment in all of these conditions is unsatisfactory and the cosmetic 
outlook poor. 

Dystrophies. Many of the above conditions are the result of 
central nervous, systemic or local diseases. They are seen in 



376 DERMATOLOGY 

syringomyelia, tabes, syphilis, the cachexias, acute febrile diseases, 
tuberculosis, psoriasis and dermatitis. After fevers transverse fur- 
rows develop and have a meaning similar to post-febrile alopecia. 
Each point corresponds to an original psoriasis lesion of the nail 
bed. Also in psoriasis (Chapter XI) scaling occurs under the free 
margin extending down and lifting oif the nail. The treatment is 
to put antipsoriatic substances on cotton underneath the nail, pre- 
viously having softened the scale with soap and hot water. Frac- 
tional doses of X-rays are also indicated. In dermatitis of the nail 
(Chapter IX) vesicles develop at the base causing dystrophies of the 
mature nail similar to those observed in psoriasis. In squamous 
dermatitis psoriatic nails are closely simulated. In both diseases 
the nails become lustreless and brittle. In psoriasis they tend to 
become thin. In chronic dermatitis they become thick, friable and 
suggest mild forms of onychogryphosis. In the erythrodermas the 
nails atrophy. 

Onychonychia is an inflammation of the nail matrix due to 
pyogenic infections, dermatitis or trauma. The nail bed is thickened 
and red. Onychia maligna is due, as a rule, to syphilis, tuberculo- 
sis or any infective ulcers at the nail border. In paronychia (pan- 
aritium or whitlow) streptococci (see impetigo contagiosa, Chapter 
XXIV) cause suppuration of the nail fold with the local symptoms 
of abscess formation. Wet dressings, and, if needed, surgical treat- 
ment produce a cure. Hangnails predispose to this. They are ex- 
foliated or injured patches of cuticle. 

Unguis incarnatus or ingrown nail is usually a disease of the 
great toe but may occur, albeit rarely, on any digit. Through care- 
less paring, neglect, or injury a sharp spike of nail at the side of 
the bed grows and pierces the cutis, continuing to grow within the 
puncture thus made. It acts as a foreign body and at first causes 
inflammation with swelling, redness and pain. Infection may take 
place increasing these signs, and it is possible for systemic infec- 
tion or phlegmon to ensue, although this is happily rare. The 
treatment is preventive and symptomatic. Prevention resides in 
careful hygiene and cutting. When the disease begins a small pad 
of cotton inserted between the nail and the flesh suffices. This should 
remain until the nail is long enough to be cut transversely from 
corner to corner. When inflammation occurs wet dressings should 
be applied, followed by the above. With infection the same treat- 
ment is indicated unless an abscess forms. Then surgery is in- 
dicated. At times it becomes necessary to remove part of, or 



DISEASES OF THE NAILS 377 

the whole, nail. This must be done under local or general anes- 
thesia. 

Hangnail is due to careless manicuring. In removing cuticle 
little fragments of epidermis may be partly lifted off with the im- 
plements. Injuries, or nail or cuticle biting produce the same effect. 
The fragment tends to tear back down to the corium and hangnails 
easily become infected and form abscesses, or suppurating paronychia. 
Likewise digital chancres begin in such lesions. The proper treat- 
ment is careful toilet of the hands and cutting away the hangnails 
down to their bases. 

Subungual hemorrhages are due to injuries, mainly blows, or 
bruises to the nail or bed. A small suggulation develops (at first 
red, then brown), under the nail. This gradually grows out with 
the nail growth. In extreme cases the whole nail may fall, but it 
grows in again. Similar injuries, careless manicuring, occupation, 
etc., predispose to transverse., or longitudinal furrows. 

Tumors, chiefly epitheliomata, develop either in the nail bed or 
under the nail. All forms are rare. The treatment is X-rays or 
surgery, according to indications (Chapter XXVIII). 

Pyogenic infections may occur in the nail bed or under the nail, 
giving the picture of suppurative paronychia. Redness, swelling or 
bleb formation (the so-called run-round) appear. The picture is 
seen in impetigo contagiosa, when it is caused by streptococci; or 
after puncture wounds, hangnails, ingrown nails, etc., when it is 
due to either type of pyogenic cocci. Rarely KLebs-Loeffler bacilli 
or Bacillus pyocyaneus are responsible. The treatment consists in 
removing the underlying cause of the impetigo, and the local appli- 
cation of wet dressings, or antiseptic creams, chiefly the conventional 
mild mercurials. 

Tuberculosis verrucosa cutis may arise about the nail (Chapter 
XXV). Fungous diseases have already been described (Chapter 
XXVI). 

syphilis of the nail 

Syphilis, either congenital or acquired, involves the nail in all 
stages by attacking either the bed or nail substance itself. Primary 
syphilis usually is seen near the fold of cuticle on the one side of 
the nail, the starting point as a rule being a hangnail or some other 
injury. Thus in primary syphilis only one nail is diseased. In 
other forms more than one nail is affected. In syphilitic periostitis 
or dactylitis, either in the secondary or tertiary stages, dystrophy of 
the nails may be produced because of secondary involvement from the 



378 DERMATOLOGY 

subjacent tissue. Thus a furrowed or distorted nail is seen, with 
a swollen, red, infiltrated phalanx. In tertiary syphilis there may 
be a gumma of the nail bed or folds, or syphilitic onychia or 
paronychia. 

In onychia syphilitica the nail becomes dull red, yellow or brown, 
is striated, furrowed, friable and often fissured. The cuticle scales, 
and the plate pits, as in psoriasis. The nail is shed and replaced 
repeatedly. Paronychia is evidenced by a dull red, infiltrated, 
scaly fold looking like chronic paronychia. Usually several nails 
are involved, or all are, and rarely ulcers or gummata develop. 

Congenital lues infrequently attacks these organs, but when it 
does the various forms described are seen just as in the acquired 
condition. The treatment is that of systemic syphilis. 



GEOUP XL SKIN DISEASES BELATED TO NERVE 
DISTURBANCES 

CHAPTER XXXVIII 

CUTANEOUS DISTURBANCES DEPENDENT UPON OR 
ASSOCIATED WITH NERVOUS DISORDERS 

Central sympathetic peripheral and functional nervous and mental 
diseases may produce, or be associated with, cutaneous manifestations. 

I. Central Nervous Diseases 

1. Epidemic cerebrospinal meningitis, spotted fever 

(Chapter VII) 

2. Tabes dorsalis, malum perforans pedis (Chapter XLIV) 

3. Syringomyelia 

4. Morvan's Disease 

5. Herpes. Ganglion hemorrhages (Chapter IX) 

II. Sympathetic Nervous Disturbances 

1. Addison's Disease, secondary to diseases of the chromaffin 

system (Chapter XVIII) 

2. Acanthosis nigricans, abdominal neoplasms, and relative to 

abdominal sympathetic system (Chapter XV) 

III. Peripheral Nervous System 

1. Lepra, neurolepra and neuroleprides (Chapter XXV) 

IV. Trophoneuroses 

1. The gangrenes and decubitus (Chapter VIII) 

2. Glossy skin (Chapter XVII) 

V. Angioneuroses 

1. Angioneurotic oedema (Chapter VII) 

VI. Mental Disease and Deficiency. Functional Diseases 

1. Recklinghausen's Disease (Chapter XXX) 

2. Granulosis rubra nasi (Chapter XXXIII) 

3. Analgesias — parasthesias, etc., of hysteria 

VII. Metabolic Diseases 

1. Uremia; pruritus, formication 

2. Diabetes, pruritus, formication 

3. Arteriosclerosis, pruritis, numbness, tingling 

VIII. Unclassified Conditions 

379 



380 DERMATOLOGY 

1. Pruritus hiemalis and paririe itch 

2. Dermatalgia 

3. Meralgia 

-i. Trichotilomania 
5. Derma tochalensia 

The cutaneous manifestations of central nervous diseases are prob- 
ably trophoneuroses and might be classified as such were it not for 
their known etiology. In tabes a perforating ulcer of the foot 
known as malum perforans pedis develops. Other causes of this 
condition are paresis, syringomyelia and various metabolic and in- 
fectious diseases involving the cord. Actually lepra and syringo- 
myelia cause more confusion than does either with tabes. Rarely a 
similar condition appears on the palm. The treatment is that of 
any ulcer and is unsatisfactory because of the nature of the under- 
lying cause. 

In syringomyelia and Morvan'a disease, because of loss of pain 
sense, all sorts of injuries and lesions may occur, and since patients 
are often unaware of them they may become large and obstinate. 
Ulcers, whitlows, vesicles and bullae form, and as the trophic dis- 
turbances become profounder spontaneous amputation of the pha- 
langes may take place. In addition hyperalgesia and hyper- 
hidrosis are occasionally observed. The treatment is symptomatic. 
All gangrenes, including decubitus (Chapter VTI). may be in this 
group, as may also be glossy skin (Chapter XVII). It is also widely 
believed that scleroderma (Chapter XVIII) too is thus to be classi- 
fied. 

Lepea (Chapter XXV) and axgioxeeeotic oedema (Chapter 
VII) have already been dealt with. The relationship of Receeixg- 
haesex's disease (Chapter XXX) and geaxelosis eebea xasi 
( Chapter XXXIII) to mental deficiency has been alluded to. This 
association is neither clear, close nor constant, In hysteria there 
may be all sorts of parasthesiae, itching, analgesia and hyperasthesia. 
There may be habits, such as scratching the skin, or pulling hairs, 
that may cause traumatic lesions, and hysterical mutilations and 
feigned eruptions (Chapter VIII), belong in this group. 

In nephritis, particularly with chronic uremia, in the acidosis of 
diabetes, in leucemia, and arteriosclerosis, there may be itching ; and 
in all but the leucemias, tingling, formication, hyperalgesia and 
analgesia may be present. These may all be regarded as derma- 
talgias, either essential, or of central nerve origin, unless an effort- 



CUTANEOUS DISTURBANCES 381 

Is made to determine the underlying cause. In every case with such 
skin phenomena examinations for the underlying cause should be 
conducted, and if the grosser metabolic changes are not found an 
expert neurologist should be consulted, particularly with the idea of 
determining a factor such as early syringomyelia. 

Pruritus or itching is the commonest symptom of skin diseases. 
Pruritus essentialis is that form in which no cause can be found. 
Another form is senile. Other varieties still are anal, vulvar, and 
nasal, the last usually due to hay or rose fever. Anal pruritus is 
often inexplicable; but often is the earliest sign of tabes, and at 
times is associated with intestinal parasites, carbohydrate fermenta- 
tion or hemorrhoids. Vulvar pruritus is usually secondary to the 
above causes or to vaginitis or diabetes. Only to those cases in which 
no etiology is ascertainable may temporarily still be applied the term 
essential pruritus, secondary to scratching which arises dermatitis 
with or without lichenification. 

In this group is winter itch, or pruritus or prurigo hiemalis. It 
always appears in cold, and leaves in warm, weather. It 
gets worse when the patient undresses. Prairie itch, a disease of 
the West, may be similar, but is more likely due to a mite. Seasonal 
itching is probably the result of hypersusceptibility of the cutaneous 
nerves to thermal changes. Similar phenomena occur in some people 
after bathing. 

The treatment of pruritus essentialis is varied and unsatis- 
factory unless the underlying factor is found, and if found, curable. 
Certain obvious indications are thus furnished. Antipruritics are 
numerous and on the whole unsatisfactory. Wet dressings, lotions 
containing one, two or five percent, of menthol or phenol, or sprays 
of these substances are sometimes useful. Mentholated (two per- 
cent.) zinc stearate powder, alone, or after such applications as have 
been mentioned, is frequently most valuable. Even mentholated or 
phenolated oils are good. Ointments are poorly borne as a rule. 
Camphor and cocaine, in various vehicles, are employed, but are 
rarely valuable. Bran and particularly mentholated starch baths 
are good. The latter may cause cardiac collapse, and phenol when 
employed over extensive areas may cause nephritis. Hence care 
should be employed in using these substances. Internally, morphine 
and bromides are often of avail, but they themselves may provoke 
itching. Pilocarpine and sweating have been recommended. The 
former is dangerous and overstimulation of the sweat glands may 
increase the pruritus and inflame the skin. 



382 DERMATOLOGY 

Dermatalgia or painful skin is rare and of many qualities, re- 
sembling the feeling or rubbing, cutting, bruising or burning. There 
are no objective signs. Meralgia is pain in the outer anterior sur- 
face of the thigh. The sensations are tingling, numbness, pain and 
other parasthesiae. Effort increases them. Treatment is unsatis- 
factory. Trichotilomania is a compulsive desire to pull at hairs. 
It is really a neurotic habit or mannerism, and may cause secondary 
lesions, infections and traumatic alopecia. Scleroderma, erythro- 
melalgia, some of the other atrophies, thromboangitis obliterans, some 
forms of acroasphyxia are considered neurological in origin. No 
satisfactory evidence thereof exists. 



GROUP XII. DISEASES OF THE VISIBLE MUCOUS 
MEMBRANES 

CHAPTER XXXIX 

DISEASES OF THE ANUS, CONJUNCTIVA, BUCCAL AND 
GENITAL MUCOSA 

Cutaneous diseases often involve the visible mucosa, and there are 
also diseases peculiar to the mucous membrane which do not involve 
the skin but which are included in the general science of dermatology. 
It is necessary to know these conditions to be an enlightened practi- 
tioner, but since a detailed description of them would of itself 
double the size of this book, they will be catalogued as briefly as 
possible. 

Conjunctiva. The conjunctiva, as compared with other similar 
tissues, is subject to relatively few of the disturbances in question. 
At times erythema multiforme and urticaria may occur at this site 1 , 
particularly angioneurotic edema (Chapter VI). Many of the pur- 
puras (Chapter VII) are found here, and, above all, the petechiae 
of sepsis. Both simple herpes and zoster (Chapter IX), the latter 
also on the cornea, are by no means rare. Pemphigus of the con- 
junctiva (Chapter X), both as bullae in pemphigus vulgaris, and as 
a condition called Graefe's essential shrinking, must not be forgot- 
ten. The pemphigus bulla easily breaks and the floor remains as a 
superficial conjunctival ulcer. The shrinkage of Graefe's form re- 
sembles cicatricial conjuctivitis. Lesions of dermatitis herpeti- 
formis rarely involve the conjunctiva. The erythrodermas (Chapter 
XII) cause very little conjunctival trouble save in a secondary sense. 
All of them, but chiefly pityriasis rubra of Hebra, are capable of 
producing ectropion with the usual consecutive conjunctival changes 
thereof. The same is true of scleroderma (Chapter XVII). Pedic- 
ulosis pubis and pediculosis capitis (Chapter XX), the former by 
its presence in the lashes, the latter by its irritation from the long 
infected scalp hairs, cause mild conjunctivitis. Tubercular (Chap- 
ter XXVI) conjunctivitis is known in children, and conjunctival 
lupus vulgaris is not rare. Conjunctival epitheliomata (Chapter 
XXVIII) are seen, particularly rodent ulcers; and in xeroderma 

383 



384 DERMATOLOGY 

pigmentosum, on the conjunctiva, together with the cornea it is a 
usual finding. Vascular nevi (Chapter XXXII) are occasionally 
seen, as a rule the conjunctival involvement being simply participa- 
tory in a process including the whole eyelid. Diseases peculiar to 
the conjunctiva belong in the province of ophthalmology. 

Diseases of the buccal orifice, including the nose, are numer- 
ous. Those peculiar to these regions will be dealt with separately 
after the general conditions have been indicated. Erythema multi- 
forme and urticaria (Chapter VI) are not infrequently seen. Par- 
ticularly the lips are involved, and in the former are often swollen 
and crusted, while in the latter (angioneurotic edema) they are 
greatly distorted. Lead poisoning (Chapter VII) and bismuth 
poisoning cause characteristic gum lines. In the exanthemata 
(Chapter VII) definite buccal signs exist. In measles Koplik's 
spots are found, in scarlatina the strawberry tongue, in German 
measles petechiae of the soft palate and uvula. The purpuras, too, 
(Chapter VII) involve buccal structures, and labial and gingival 
petechiae are common in sepsis. Early in mumps an erythematous 
ring surrounds, the opening of Stensen's duct. After measles and in 
other wasting diseases (Chapter VIII) noma and nosocomial gan- 
grene develop. Herpes (Chapter IX), and zoster in all parts of the 
mouth and nose, are by no means rare. Pemphigus vulgaris (Chap- 
ter X) is common in the mouth, and even the lesions of dermatitis 
herpetiformis, bullous erythema and urticaria are not unknown. 
Psoriasis (Chapter XI) is rare. The erythrodermas (Chapter 
XII), chiefly pityriasis rubra of Hebra, cause ectropian of the lips. 
The lips, mucosa of the cheeks and tongue are commonly involved in 
lichen planus (Chapter XIII). Scleroderma (Chapter XVII) 
causes changes in the lips similar to those in the eye. Addison's dis- 
ease (Chapter XVIII) characteristically produces buccal pigmenta- 
tion. Diphtheria (Chapter XXIII) causes well known mouth 
lesions, and in typhoid fever ulcers on the anterior faucal pillars 
are encountered during the prodromal period and first week. Vin- 
cent's angina must not be overlooked. Streptococci (Chapter 
XXIV) cause perleche. The various forms of tuberculosis and 
lepra (Chapter XXV) seen in the nose, mouth and larynx need only 
be mentioned to reveal their importance. Lupus erythematosus 
(Chapter XXV) is seen on the lips. As to non-infectious granu- 
lomas (Chapter XXVI), it is essential to remember that acute leu- 
cemia may cause tonsilar changes suggesting diphtheria and Vin- 
cent's angina. Warts (Chapter XXVII) occur on the lips, and 



ANUS, CONJUNCTIVA, BUCCAL AND GENITAL MUCOSA 385 

lesions resembling multiple warts or pointed condylomas are noted 
in the mucosa of the lips and cheeks. All sorts of epitheliomata 
(Chapter XXVIII) are seen on the lips, tongue and elsewhere. In 
this connection, and particularly with reference to sarcoma (Chapter 
XXXI) confusion with salivary ranulae and Miculicz's disease is 
possible. Xevi, particularly the vascular and lymphatic, are com- 
mon. Syphilis appears in its primary form on the lips, tongue, 
tonsil and uvula ; in its secondary form, throughout the buccal orifice 
as mucous patches; in its late forms, as gummata of any of the 
structures but prevailingly of the tongue. Interstitial glossitis is 
common, and throughout the mouth specific leucoplacia is frequently 
seen. 

A few special points concerning buccal forms of diseases not re- 
stricted to the mouth, and a few diseases peculiar thereto require 
further emphasis. Of the latter some are seen on the lips, some on 
the tongue, some on the entire mucosa. On the whole these condi- 
tions demand no great space. 

A. Diseases peculiar to the tongue. 

I. Anomalies 

1. Grooved tongue 

2. Scrotal tongue 

II. Infections 

1. Black hairy tongue 

2. Sprue 

III. Inflammations 

1. Moeller's glossitis 

2. Erythema migrans 

B. Diseases peculiar to the lips 

I. Anomalies 

1. Fordyce's disease 

II. Infections 

1. Perleche (Chapter XXIV) 

III. Inflammations 

1. Cheilitis glandularis exfoliativa 

C. Diseases peculiar to the entire buccal mucosa 
I. Inflammations 

1. Ulcerative stomatitis 

2. Foot and mouth disease 

D. General diseases involving the buccal mucosa and requiring 

special mention 



386 DERMATOLOGY 

I. Inflammations 

1. Leucoplacia buccalis 

2. Lichen planus (Chapter XIII) 

3. Lupus erythematosus 

II. Infections 

1. Syphilis 

a. Chancre (Chapter XLI) 

b. Mucous patches (Chapter XLII) 

c. Gummata (Chapter XLIII) 

d. Interstitial glossitis (Chapter XLIII) 

2. Tuberculosis 

a. Miliary ulcers (Chapter XXY) 

b. Tubercular granulomata (Chapter XXV) 

c. Lupus vulgaris (Chapter XXV) 

3. Vincent's angina 

III. Neoplasms 

1. Epitheliomata (Chapter XXVIII) 

Grooved Tongue is simply a tongue in which the ordinary markings 
are intensified. When that is so to a marked degree the convolutions sug- 
gest the topography of the scrotum. This is the scrotal tongue. 

The Hairy Black Tongue is the result of a hypertrophy of the filiform 
papillae which may reach an inch in length. They form a wedge on the 
dorsum. Many suppose a yeast fungus causes the condition. Sprue is a 
fungus disease of the tongue, epidemic at times in institutions, and char- 
acterized by the presence of white spots, due to a membrane consisting of 
epithelial detritus and the infective agent, the white oidium. Moeller's 
glossitis is a rare disease of the dorsum and margin of the tongue. The 
affected areas are glossy, red, swollen and extremely painful. The cause 
is unknown. Erthyema migrans or glossitis areata, or transitory benign 
plaques of the tongue is characterized by rings, the red margins of which 
wander, forming gyrate figures suggesting erythema multiforme. Within 
the red border is a white zone of oedema or exfoliation, and the centre of 
the large lesions is normal. This condition is also called geographical 
tongue. Fordyce's Disease is an anomaly. Misplaced sebaceous glands 
are seen on the inner aspect of the lips and cheeks, particularly the lower 
lips. The affected area is covered with scattered white or bluish white 
rather hard spots or globes, the size of a pin head. They are minute 
sebaceous cysts. Cheilitis glandularis is a rare exfoliative disease of the 
lower lip which is swollen, tense and covered with minute elevations cor- 
responding to mucous glands with enlarged openings. The best treatment 
is with X-rays. Nothing is known of the cause. 

Ulcerative stomatitis, canker sore or aphthous stomatitis is a 
condition in which minute ulcers form on the lower lip, below and 



ANUS, CONJUNCTIVA, BUCCAL AND GENITAL MUCOSA 387 

on the tongue. They are grey or yellow and have a narrow inflam- 
matory red zone about them. They are sparse or numerous and pain- 
ful. They rarely exceed a diameter of two millimeters. They are 
either infectious or herpes simplex. The best therapy is to paint 
them with twenty percent, silver nitrate solution. Foot and mouth 
disease is closely related, and is supposed to be similar to a condi- 
tion seen in cattle. In man it causes aphthous ulcers and mild fever. 

Lettcoplacia buccalis is a chronic hypertrophic inflammation. 
It is pearly white, occurs in thickened, roughly circular or oblate 
patches which are sparse or numerous. Syphilis is its commonest 
cause and it predisposes to cancer. Lichen planus closely resembles 
it, but the patches are not smooth, are striated as on the skin, and 
most obstinate. Lupus erythematous prefers the lips. A white or 
gray hypertrophic margin with a red center, similar to that of a skin 
patch, characterizes the process. Details of syphilis and tuberculosis 
of the mouth are found in other chapters. 

Vincent's angina closely resembles chancre, gumma or diphtheria, 
particularly when the tonsil is involved. On other areas of the 
mucosa mucous patches are simulated. The cause is Vincent's spi- 
rillum, and the treatment arsphenamin locally and intravenously. 

Epithelioma of the lip and tongue is usually squamous and 
very malignant, involving the glands and metastasizing early. Epi- 
thelioma of the tongue is usually single, opposite the molars, often 
arises from leucoplacia, is painful, and the pain is referred to the ear 
on the corresponding side. Glandular enlargements develop. The 
only therapy is radical operation. A cancer may simulate a chancre 
or gumma. The chancre contains spirochaetes, but it must be re- 
membered that the pallida and microdentium are similar. Other 
evidences of syphilis must be sought. Gummata are usually mul- 
tiple, but a gumma and cancer may coexist. In case of diagnostic 
difficulty a complete excision of the suspected growth should be 
made, and a microscopic examination should follow at once of frozen 
sections, the surgeon being ready to proceed with an immediate oper- 
ation. 

Anal diseases within the province of the dermatologist are not 
numerous. Dermatitis (Chapter IX) pemphigus, particularly pem- 
phigus vegetans (Chapter X), which may be confused with flat 
condylomata, and psorospermosis (Chapter XIV) are seen more or 
less, according to the incidence of the respective diseases. Derma- 
titis is the commonest, particularly with pruritus ani. Pruritus is 
often inexplicable but may be an early sign of tabes dorsalis, or be 



388 DKRMATOLOGY 

associated with itchy dermatoses, colitis, proctitis, hemorrhoids and 
starch indigestion with acid stools. Constipation is often respon- 
sible. The underlying cause must be removed, and Roentgen therapy 
is excellent. Secondary to pruritus, lichenification arises. Furun- 
cles are often found near the anus. Tuberculous ulcers and various 
types of syphilides, particularly the chancre, mucous patches, flat 
condylomas and gummata are common. Epitheliomata (Chapter 
XXVIII) are not rare. 

Diseases of the glans penis and mucous surface oe the pre- 
puce are dermatitis (Chapter X), herpes (Chapter IX) known as 
herpes progenitalis, balanitis, pemphigus (Chapter X), lichen planus 
(Chapter XIV), scabies (Chapter XX), erosive balanitis, soft chan- 
cres (Chapter XXIII), rarely tuberculosis (Chapter XXV), ver- 
rucae and pointed condylomas (Chapter XXVII), epitheliomata 
(Chapter XXVIII), the primary lesion of syphilis, mucous patches 
and gummas. 

Diseases of the vulva are dermatitis and herpes (Chapter IX), 
pemphigus vulgaris and vegetans (Chapter X), kraurosis (Chapter 
XVII), scabies (Chapter XX), furunculosis (Chapter XXII), ulcus 
molle (Chapter XXIII), tuberculosis (Chapter XXV), verrucae 
(Chapter XXVII), epithelioma (Chapter XXVII) and syphilis, par- 
ticularly the chancre, mucous patches, moist papules, flat condylo- 
mata and gummata. Pruritus vulvae is analogous in significance 
and causation to pruritus ani, and is also often secondary to vaginitis 
both specific and non-specific. 

In all of the conditions described in this chapter the therapy has 
been indicated in other places in connection with descriptions of 
the individual diseases. The points raised with reference to syphilis 
in its various mucous manifestations will be elaborated in the de- 
scription of this disease. 



SECTION F. SYPHILIS 



CHAPTER XL 

GENERAL ASPECTS OF SYPHILIS 

Mode of Infection and Infectious Mechanism. To understand 
syphilis, it is necessary to bear in mind some of the general facts, as 
they are to-day conceived, of the biology of the spirochete and host in 
their inter-relation. In other words, a practical understanding of 
the infectious mechanism constitutes the only basis upon which can 
be founded a rational insight into the clinical peculiarities and thera- 
peutic problems of the disease. The cause of syphilis is a microor- 
ganism, probably a protozoon, possibly a member of the protista, 
that gains access to the host through an injury to the skin or mucous 
membrane. After an incubation period of from ten days to six 
months, the average, however, being three weeks, at the site of inocu- 
lation a sore develops. This lesion, if unmodified by treatment, 
persists for from three to six weeks and spontaneously involutes, 
leaving a more or less distinct scar which may or may not be pig- 
mented. While this is going on the microorganisms are being dis- 
seminated throughout the host, the disease becoming generalized or 
systematized. The period of dissemination varies in length, usually 
extending over a number of years, and being characterized by waves 
of activity and quiescence, but gradually growing more restricted in 
its objective evidences. Finally, and lasting for years or perhaps 
through life itself, there are recrudescences of the restricted or local- 
ized phenomena. Each of the phases or stages mentioned has its 
own significance and has been given a special designation. The 
period elapsing between the exposure and appearance of the first 
sore is known as the primary incubation period. The first sore, 
itself, is known as the primary or initial lesion (Chapter XLI). 
The interval between the onset and general dissemination is called 
the secondary incubation period. The active era of dissemination is 
termed the secondary stage (Chapter XLII), or period of early 
syphilis, and the inactive recesses taken by the malady during this 
stage are called periods of secondary latency. Late or restricted 

391 



392 DERMATOLOGY 

manifestations constitute the so-called tertiary stage (Chapter 
XLIII) and it, too. is characterized by rising and receding tides of 
activity separated by periods called tertiary latent periods. 

Definition. Thus, syphilis is a chronic infectious disease run- 
ning a course covering a number of years, and obviously having a 
tendency to self-limitation. This tendency evinces itself not only 
in the behavior of the malady as a whole, but also at every major and 
minor step in its progress. Such evidence of this as we possess will 
be adduced below, when each of these steps is more fully described, 
but it may here be stated that the peculiarities of the disease must 
depend either upon phenomena in the life cycle of the parasite, or 
upon peculiarities of the host's protective mechanism, or. what is 
more likely, upon both. Before going into this, however, it would 
be well to become familiar with the parasite itself. 

The Spriochete. The organism is a highly motile, flagellated, re- 
fractile body, from fifteen to forty microns long, that can best be 
studied by dark field illumination, and while alive. Its mode of 
division is not definitely known : it grows anerobically on Xoguchi's 
medium, and it may be capable of entering into resting or encysted 
stages. In breadth, it is but a fraction of a micron, and it is wound in 
fine spirals like a spring, perfectly even and from twelve to twenty in 
number. Its movements are complicated, and consist of a corkscrew 
forward or backward motion upon the long axis, and a bending motion 
upon a point at or near the middle, as a fulcrum. At times it is pos- 
sible to see the fiagellae at the delicately tapered tips, lashing about. 
but these organs can best be demonstrated in dead specimens sub- 
jected to the Giemsa stain. Meierowski has found bodies which he 
takes to be nuclei, and which he regards as connected with the pro- 
creative phases of the organism. The spirochete is also called the 
treponema pallidum, by virtue of its striking palor when stained. 
In genital lesions, it must be differentiated from a coarser related 
organism, the spirocheta refringens, which is once or twice its size. 
and eel-like in contour. In mouth lesions are found, not only the 
above saprophytic organism, but also another, more capable of caus- 
ing confusion because more like the syphilis germ in appearance. 
This is the spirocheta microdenitium. which differs from the spiro- 
cheta pallida only in length. It is equally delicate, but very short, 
showing but six or eight twists, and it is less active. The organism 
of syphilis was discovered by Schaudin. 

Dissemination of the Spirochete. As stated, the portal of entry 
is a solution in continuitv in the skin or mucosa. Because trans- 



GENERAL ASPECTS OF SYPHILIS 393 

mission usually takes place during coitus the initial lesions is nearly 
always situated upon the external genitals. At the moment of infec- 
tion the spirochetes gain a foothold in the injured tissue, multiplying 
and invading the local lymphatics, and rapidly entering the lymph 
vessels. This must occur very quickly, as was illustrated in his 
lectures by Jacobi of Freiburg. A student with herpes, within 
twelve hours of intercourse with a woman he discovered immediately 
post coitum to be actively syphilitic, was circumcised, with the hope 
of thus warding off infection. Although no primary lesion ever de- 
veloped, in due time the secondary stage appeared. This gives a 
good idea of how soon the organisms get far beyond the site of inocu- 
lation, and how futile the attempts are to modify the gravity of the 
disease by excising a fully matured initial lesion, a procedure once 
widely advocated. At its inception, syphilis is a disease of the 
lymphatics, and its early avenues of dissemination are restricted to 
this system. If a chancre be studied histologically by the Levaditi 
method, the perivascular lymph spaces will be found filled with the 
microorganisms, and here and there one of the latter will be seen 
penetrating the wall of a small blood vessel, thus entering the gen- 
eral circulation. In other words, the manner of spreading has now 
become twofold, hematogenous and lymphatic. This is what goes on 
during the initial stage after the development of the primary lesion. 
In the meantime, the chancre has begun to involute. Undoubtedly, 
this must be the result of a developing local immunity, on the part 
of the affected tissue. But the host has been completely invaded by 
multiplying organisms, and the secondary incubation period is over. 
The Biology of the Early Stage. With the conclusion of the 
latter, the disease has reached the secondary or eruptive stage, one 
characterized by tissue responses, and subjective and objective symp- 
toms referable thereto in all body organs. The host has now become 
a huge battle field in which the spirochetes, armed with their toxins, 
wage war against the host's cells defended by immunizing substances, 
whatever they may be. With that niggardly economy so often wit- 
nessed in nature, immunity never seems quite to suffice at a given 
moment, and whereas the invaders may be stemmed, they are evi- 
dently not entirely routed. Instead, they gather their forces, and 
wave upon wave sweeps over the host, the invaders possibly going 
into resting or resistant stages, as do malaria plasmodia, until in 
moments of immune inadvertence, they burst forth anew. This 
accounts for the periods of secondary latency. Belated to the resis- 
tance mechanism is the Wassermann reaction, a complement fixation 



394 DEKMATOLOGY 

phenomenon, which albeit not specific, nevertheless must be either an 
index of immunity, or an index of activity on the part of the spiro- 
chetes. At any rate, it is always positive during active syphilis, 
except in the malignaut forms, and under certain other conditions 
which will be outlined below. 

During the secondary stage there is a disseminated, symmetrical, 
generalized exanthem, capable of assuming many forms; there are 
general glandular enlargements, mucous lesions of various kinds, 
headaches showing meningeal involvement, myalgias, neuralgias, 
arthralgias, and there may even be evidences of involvement of the 
abdominal and thoracic viscera, and organic changes in the brain, 
cord, and organs of special sense, particularly the eyes and ears. 
Fever sometimes occurs. In short, at this period the disease is a 
generalized infection, varying in intensity according to the virulence 
of the germ, or the resistance of the host. Should the former be 
excessive, or the latter too slight, malignant syphilis supervenes, a 
form in which very early tertianism with rapid death results. 

The Tertiary Period. Normally, however, no such dramatic and 
varied picture occurs. On the contrary, superficially regarded, the 
disease seems to be mild, and therein resides its insidious peril. 
Gradually, the host becomes habituated to the prolonged task of re- 
sistance, and the virulence of the infection wanes. The transforma- 
tion from the relatively stormy to the comparatively calm tertiary 
period has gradually taken place, and finally this period, apparently 
more innocuous, but actually quite as- dangerous, has set in. The 
lesions are now no longer widely disseminated, but restricted to one 
or a very few organs or tissues, and recur and wane persistently at 
given sites. Thus, the skin or bones or heart or vessels or central 
nervous system, for example, may be the scene of recurrent activity, 
subject either to tissue affinities of different strains of spirochetes, 
or to susceptibility on the part of different tissues, or both. The 
determining factors vary with race, occupation and habits of living. 
The Chinese, whose mentality is in abeyance, rarely, it is said, get 
nerve syphilis as compared with Caucasians. Alcoholics are subject 
to nerve and cardiovascular involvement. Heavy indulgence in 
tobacco, and severe physical work also seem to favor syphilitic suscep- 
tibility of the circulatory system. 

The Disease as a Whole. Ultimately, and in spite of every- 
thing, a certain number of syphilitics seem to recover completely 
even without treatment, but this is rare, and negated by the studies 
of Warthin, who proved that even in clinically apparently cured 



GENEKAL ASPECTS OF SYPHILIS 395 

cases, spirochetes could be found in the heart without any inflam- 
matory reaction, dwelling there symbiotically and perhaps capable 
of reactivation to pathogenic potency. 

Syphilis thus, throughout its course, is remarkable for its remis- 
sions in activity. In other words, the host gradually, as time goes 
on, tends effectively to limit the virulence of the invading agent. 
So far as complete elimination of the invader is concerned, this is 
probably never accomplished. Whether or not the disease assumes 
serious forms will depend upon the extent to which have been per- 
manently damaged the tissues subjected to the concentrated activities 
of the spirochetes. This in turn will depend upon tissue peculiar- 
ities, or upon peculiarities of the spirochetes themselves. Without 
doubt the disease must be controlled by the host's ability to generate 
antibodies sufficiently early to prevent serious inroads upon impor- 
tant structures. The precise mechanism, and the exact nature of 
the protecting bodies is not known, but roughly the Wassermann 
reaction seems to be connected with the process. The test is practi- 
cally always positive during periods of activity. 

The Wassermann Test. Without exhaustively entering into the 
matter, the fixation test is found negative during the first incubation 
period and in the early days of the chancre, growing more likely to 
be positive as the secondary period approaches. During activity in 
the secondary stage, the test is always positive, and it may be so 
during intervals of latency in this period, but may equally often be 
negative. The same is not true in the tertiary stage, for here at 
times it is negative in the presence of clinical activity. When it is 
negative at such times of obvious activity, the discrepancy is possibly 
due to a failure in the protective mechanism of the host. This is 
still speculative, however, for it is not thought that the substances 
giving the reaction are identical with the immunizing bodies. Nev- 
ertheless, there seems to be some parallel between the two. Malig- 
nant syphilis, a form running a rapid course, and soon acquiring 
tertian features, often presents a negative serum test. Since malig- 
nancy, or better precocity, depends upon a failure in protection, 
there is reason to believe that the fixation phenomenon is closely re- 
lated to immunity. 

The test often becomes transiently negative, as shown above, before 
the patient can possibly be cured. Thus, it requires great experi- 
ence with the subject properly to interpret the negative reaction. A 
positive reaction in syphilis invariably indicates activity, but the 
phenomenon is found also in yaws and nodular lepra, as well as in 



396 DERMATOLOGY 

some other conditions. Therefore, knowing the rules and exceptions 
as to the positive test, it is easy enough to interpret it. Xot so with 
the negative ! It indicates latency, an inadequate protective mechan- 
ism, or cure, according to the stage and character of the disease, and 
the quality and persistence of the treatment. Since the matter 
included in the previous sentence is worthy of a treatise in itself, 
the implied hints will urge conscientious and intelligent practitioners 
to grasp the truth that there is something to syphilis diagnosis and 
prognosis "besides the serum test ; that a positive test does not always 
indicate syphilis; and that a negative one requires study before it 
can be applied in practical syphilology. 

Treated Syphilis. The foregoing paragraphs outline untreated 
syphilis. When treated, the course is greatly modified. If treat- 
ment is begun in the primary stage, the disease may be aborted, and 
none of its later manifestations develop. In like manner, progress 
of the disease, in favorable cases, may be cut short- at any of the later 
stages. In general, the earlier treatment is instituted, and the more 
intensively it is pursued, the greater the probability of eliminating 
pictures which formerly were common. Thus, in civilized parts 
of the world, the late cutaneous manifestations are becoming scarcer, 
and it is to be confidently expected that modern therapy will com- 
pletely draw the fangs of the disease. There will then no longer 
be those remote results of the malady once called para and meta- 
syphilis, but which to-day we know to be syphilis itself, and due 
just as much to the spirochete as is the chancre. In fact, all 
syphilitic lesions in all tissues are generically alike in minute struct- 
ure, the variations being only those determined by the normal an- 
atomical peculiarities of the various tissues themselves. Xor is 
there any real difference between a secondary papule and a tertiary 
gumma microscopically, except in degree. 

To understand all these facts is to understand syphilis, and if 
they are grasped, the ensuing chapters will not be difficult. Xeither 
will it be difficult to analyze the objects of therapy. The treatment 
of syphilis has, for its aim, to destroy the spirochetes before they 
are inaccessibly intrenched in vital organs, to aid the host when 
his immunizing resources are inadequate, and as rapidly as possible 
to limit the process so that the patient may be cured, if not academi- 
cally, at least to such a degree that in the normal span of human 
life the disease can never become a menace. 



CHAPTEE XLI 

ACQUIRED SYPHILIS. PRIMARY STAGE 

Synonyms. Chancre, Hard Chancre, Hunterian Chancre, Initial 
or Primary Sore or Lesion, Sclerosis; Fr. Chancre, Sclerose, Acci- 
dent Primitif ; Ger. Schanker, Initial Affekt, Primar Affect, Indura- 
tion, Sklerose. 

The incubation period of syphilis may be ten days or three months, 
but its fairly uniform time is three weeks. At the expiration of this 
period the first clinically visible evidence of the disease appears. 
This is the primary lesion and its site is most often on or near the 
genital organs. Less frequently it appears elsewhere on the body. 

Symptoms. The chancre is a granuloma which may or may not 
break down. In the former event it is a papule, nodule or tumor, 
according to its size: in the latter it is an erosion or ulcer. The 
combinations of size or type of necrosis furnish the possibility of 
a great variety of clinical pictures. Although the chancre tends to 
be solitary it is by no means rarely multiple. Multiplicity depends 
upon either inoculation of multiple injuries, usually herpes progen- 
italis, or upon infections of contiguous surfaces, the one from the 
other, as the glans and prepuce. Thus this sort of initial lesion 
is in a relatively circumscribed area. Very rarely initial lesions 
may be multiple and widely separated as on the genitals and lips. 

When the lesion first appears it looks like a small papule and it 
may never exceed this size, or it is a nodule or, as has been said, a 
tumor. The unbroken sores are usually stony hard and dry. The 
erosions and ulcers are usually found in a hard inflammatory in- 
filtration of variable size. The ulcerative forms are usually saucer 
shaped with an indurated shallow margin, rarely undermined. 
These necrotic lesions secrete a serosanguinous, at times purulent 
and fetid, substance which is highly infectious. The secretion forms 
a crust the removal of which leaves a slightly bleeding surface. 

The primary lesion is coppery, or dusky red or purple, very hard 
to the touch, in fact usually cartilaginous or stony. But it must be 
remembered that all of these characteristics may fail and a certain 
diagnosis be impossible by the unaided eye. The lymph vessels 

397 



398 DERMATOLOGY 

leading from the chancre to the regional lymph nodes are very often 
palpable. On the penis the dorsal lymph vessels are easily felt as 
hard cordlike structures leading to the pubic symphysis. Within 
five days after the chancre's appearance, and progressively increasing 
thereafter up to the eruptive stage the local glands enlarge. They 
are hard, but elastic rather than stony, and give the impression of 
a chain of beads. They are usually painless, and rarely even 
slightly tender. The glands immediately draining the infection 
are earlier involved than those more remote, and the first gland to 
drain the lesion is the largest of the affected group. This is called 
the pilot gland by some, and the fact is noted to acquaint the reader 
with an inapt term which, however, has great vogue. 

Course. The chancre ordinarily begins to heal of itself, even 
when untreated, in from three to six weeks, or at the approach of 
the period of dissemination, known as the secondary stage. Usually 
no subjective symptoms accompany the primary lesion, save when 
associated with the secondary period. The site of the healed chancre 
is permanently marked by a scar, at first pink and later brown or 
white. The scar is soft, pliable and covered with a finely wrinkled 
integument or mucosa,, more or less depressed according to the volume 
of the original infiltrate. When stretched the scar is glossy. Oc- 
casionally chancres are phagedenic. 

Varieties. The varieties of chancres depend upon various cir- 
cumstances. As already stated they may be multiple or single, and 
practically any of the following may in turn enter in the foregoing 
group. In addition there are the ulcer (Fig. 80), papule, erosion 
(Fig. 82), plaque and indurated edema. The ulcer or Hunterian 
chancre (Fig. 80) is a saucer shaped lesion with a slightly granular 
surface. It is pink or more commonly copper, hard and has a shal- 
low slightly raised hard margin which is rarely undermined. It 
may reach a diameter of three fourths of an inch. The papule, or if 
larger, the nodule, is stony hard, coppery and dry. The erosion is a 
papule with a superficial ulcer which has a serous secretion that 
forms crusts. The plaque is a thin discoid coppery patch. It is 
rare and feels like cardboard. The indurative edema is usually on 
the vulva. The entire involved lip is swollen, hard, and coppery or 
purplish in hue. Indurative edema is sometimes seen on the prepuce 
independent of, or associated with other forms of chancres. 

Chancres are usually on the genitalia, but often elsewhere. The 
latter are qualified as extragenital (Fig. 81), On the penis the com- 



ACQUIRED SYPHILIS. PRIMARY STAGE 399 

monest site is the corona, then the prepuce, glans, meatus, shaft and 
finally the dorsum of the root. In the female the commonest site is 
the vulva (Fig. 83), at the fourchette, on the lips or near the meatus, 
and the cervex. At times instead of a visible initial lesion, a gen- 
eral primary syphilitic vulvitis exists. Because so many initial le- 
sions are cervical this stage of the disease is often missed in women, 
a fact which increases the danger of transmission in coitus, and 
which exposes unwary physicians and nurses to infection in their 
work. Extragenital chancres, which also assume any of the forms 
mentioned, occur most frequently on the lips, tongue, fingers, tonsils, 
near the genitalia, and finally anywhere else on the body. 

We must become familiar with the terms reinfection, super- 
infection and chancre redux. The reinfection is a primary lesion in 
a previously cured syphilitic suffering a subsequent inoculation. A 
superinfection is an initial lesion in a syphilitic whose first infection 
has so nearly run its course that he is already susceptible to a new 
infection. The chancre redux is a chancre that periodically returns 
at the same site without new exposure. It is difficult to say whether 
this may not be a gumma, save for the fact that motile spirochetes 
may be demonstrated in it, as well as in the reinfection, superinfec- 
tion, and ordinary primary lesion. The three types mentioned are 
rare and the student need concern himself with them no further than 
to know the terms and their significance. 

At times syphilis begins without any demonstrable initial sore. 
This may be due to the fact that there is none (syphilis d'emblee) or 
to the fact that the lesion is so situated as to elude the patient or 
physician. The former circumstance is very rare. The latter group 
comprises urethral chancres in the male, cervical chancres in the 
female, rectal chancres, and chancres so deep in the pharynx or 
larynx, that their presence is unsuspected. Only proper examina- 
tion with suitable specula or other appliances, reveals their pres- 
ence. But a word must be said as to the masculine urethral chancre. 
A serous urethral discharge appears containing no gonococci. Such 
a discharge should be examined for spirochetes. On palpating along 
the urethra's course a lump is felt. Endoscopy shows this lump. 
If it is large enough, symptoms of stricture are present. 

Phagedenism in chancres is uncommon, but at times the hard and 
soft chancres are associated. This is the chancre mixte, and usually 
the symptoms of the soft chancre with large inguinal buboes domi- 
nate the picture. The soft chancre is not indurated, is irregular in 



400 DERMATOLOGY 

outline and has undermined edges and a purulent margin and base. 
At times pure initial lesions are small, nondescript and soft and their 
recognition by the eye alone is impossible. 

Diagnosis. Aside from the clinical features of the initial sore 
the diagnosis depends upon a demonstration of the treponemata. 
This is best done by means of the dark field. Before attempting 
this procedure a wet dressing of normal saline should be applied for 
twenty-four hours or longer, partly to soften the crusts and partly 
to eliminate destruction of the spirochetes by antiseptics used by 
patients before they decide to consult a physician. In non-ulcerous 
lesions this is less necessary. The chancre is scratched lightly by 
a sharp implement, and the serum which oozes forth contains the 
spirochetes. Often examinations on successive days are required 
before the organism is found. No matter how distinctive the clinical 
aspect of a suspected sore may be, microscopic corroboration is 
urged. Negative findings are only of relative value, as the patient 
may present himself so late that the lesion is beginning to involute 
and contain only few if any spirochetes. Lip and mouth chancres 
contain spirochaeta microdontia as well as pallida, and care must be 
exerted not to confuse these two, as the former is not pathogenic. 

In early chancres there is no Wassermann reaction, but as the 
secondary period approaches the serum change appears. Thus the 
incidence of the reaction in primary syphilis is in an ascending 
curve, starting from zero at the appearane of the lesion and 
reaching 100% with the onset of the secondary stage. The curve is 
gradual up to the tenth day of the second incubation period and steep 
from thence. Obviously the Wassermann test is of no value in 
primary syphilis unless positive, in which case it heralds approaching 
dissemination of the disease. 

All primary lesions anywhere may clinically resemble certain 
secondary lesions, gummas, ulcerative tuberculosis, blastomycosis, 
sporotrichosis and epithelioma. Further, at certain sites chancres 
may suggest or be inoculated upon non-specific lesions characteristic 
of these sites. 

The secondary lesions simulated by the primary are moist papules 
(Chapter XLII) whether single or grouped. The latter are not 
indurated but contain spirochetes and show adenopathies. The 
glands however are generally swollen in this stage, and the history 
excludes error save where no chancre has ever been present. The 
only practical issue is one of prognosis, for, as will be seen, the 
earlier treatment is begun after the onset, the better the outlook for 




Fig. 80. HUNTERIAN CHANCRE 

The margin is slightly rolled, the surface of the 
lesion is glistening, red, and suggests granulation tis- 
sue. A soft chancre would show undermined edges 
and a more irregular margin, but very frequently the 
hard simulates the soft chancre. Frequently, too, hard 
chancres are multiple. 




Fig. 81. EXTRAGENITAL CHANCRE 

This picture shows the nodular, non-ulcerating initial lesion associated 
with secondary syphiloderms. On the chest is a macular rash or 
roseola; on the chin, scaling papules. 




Fig. 82. CHANCRE (MEATUS) 



A shallow, hard ulceration appears at the penile orifice. 
The swelling in the right groin indicates the enlargement 
of the inguinal glands. A maculo-papular rash appears on 
the belly and thighs. 




Fig. 83. CHANCRE (VULVA) 

A large ulcer is seen on the right larger labium. The 
margin is elevated and there is a large amount of edema 
of the labium. 



ACQUIRED SYPHILIS. PRIMARY STAGE 401 

aborting the malady. Gummas often resemble chancres, but spir- 
ochetes are absent and there is no regional glandular enlargement. 
Tuberculosis, blastomycosis and sporotrichosis are differentiated by 
the absence of spirochetes, by demonstrating the respective organisms, 
and possibly by the histology of the lesions. 

Epitheliomas are recognized by the age at which they occur, 
although primary lesions often appear at the so-called cancer age: 
by the absence of spirochetes and histologically (see Chapter 
XXVIII, Diagnosis of Epitheliomas). In this connection it may 
be well to add that when clinical and laboratory procedures fail 
us the only method remaining to establish the diagnosis of syphilis 
is to await the arrival of the secondary manifestations, a temporizing 
and dangerous delay, fortunately not often necessary, but which is 
better than erroneously stigmatizing a human being as syphilitic. 

A furuncle of the penis and lip may either resemble or become 
the site of a chancre. The diagnosis depends upon the clinical and 
laboratory data already so often adverted to. The same applies 
to herpes of these sites. Soft chancres and balanitis errosiva et 
gangrenosa may possibly cause confusion (Chapter XXIII). Lin- 
gual chancres, epithelioma and tuberculosis of the tongue are differ- 
entiated clinically, bacteriologically and histologically. The spir- 
ochaeta microdentia here can cause great confusion. Chancre of the 
tonsil may be confused with Vincent's angina. The diagnosis often 
resolves itself into demonstration of the respective organisms. 

Prognosis. Chancres always disappear spontaneously, but much 
more rapidly (sometimes in ten days) under vigorous general treat- 
ment. The prognosis in a larger sense is that of syphilis. 



CHAPTER XLII 

ACQUIRED SYPHILIS. THE SECONDARY STAGE OR PERIOD OF 
DISSEMINATION AND FLORITION 

At about the time that the chancre is almost or completely in- 
voluted, or shortly thereafter, clinical evidence asserts itself of the 
general invasion of the host by the parasite. This evidence consists 
of symptoms and signs. The secondary stage may be denned as 
that phase in the development of syphilis in which clinical phenomena 
appear, dependent upon invasion of all organs by the causative agent. 

Symptoms. There may be no subjective phenomena. More 
commonly there are severe nocturnal general headaches and variable 
degrees of sore throat, arthralgia, myalgia, and ostalgia, with in- 
creased severity of the pain at night. The arthralgia in its intensity 
may simulate acute multiarticular rheumatism, and the ostalgia 
osteomyelitis, but swelling and redness of the joints are lacking. 
Rarely there is low fever, and more rarely still pyrexia with morn- 
ing remissions and a variable degree of prostration. There may also 
at times be icterus or jaundice but without the symptoms of chole- 
lithiasis, cholecystitis or gastroduodenitis. Infrequently albumi- 
nuria, and, more infrequently still, acute nephritis even of the hemor- 
rhagic type is observed. 

Signs. The signs of secondary syphilis are cutaneous, mucous, 
glandular, visceral, skeletal, circulatory, central or peripheral nervous 
and humoral. By far the most important are the first three. Like 
so many infectious diseases the eruptive manifestations of syphilis 
are exanthematous and enanthematous. To understand the main 
feature of the secondary rash it is necessary to remember that since 
this stage is that of dessemination the eruption is both general and 
symmetrical. Furthermore, it consists of macules, papules and 
ulcers, or some combination of them, and no part of the body is 
without them. The sub types of the lesions are numerous and this, 
together with the combinations they fall into, creates a varied pic- 
ture. The sites of the eruption are the chest, abdomen, back, face, 
palms, soles, neck, and flexor surfaces of the extremities rather than 
the extensor, but by no means exclusively so. There are also pig- 
mentary disturbances and alterations in the hair and nails. The 

402 



ACQUIRED SYPHILIS. THE SECONDARY STAGE 403 

eruption rarely itches save in negroes, and even among them pruritis 
is uncommon. In body folds the lesions tend to vegetate. 

The mucous lesions (Fig. 88) are seen in the pharynx, on the 
vulva, in the vagina, on the cervix, the glans, prepuce and at the 
anus. They are prevailingly superficial, grayish ulcers, and par- 
ticularly the genital and anal lesions fungate. 

The ulcers are called mucous patches, the fungating lesions flat 
condylomas. Secondary ulcerative proctitis is scarcely rare but is 
not common. Although not quite in place here, it may be paren- 
thetically stated that in the axillae, under the breasts, the umbilicus 
and groins and in other folds in the adipose, fungation occurs form- 
ing flat condylomas. 

The lymph glands all over the body are enlarged. Thus these 
organs, discrete, somewhat hard, indolent, painless and insensible, 
are visible or palpable wherever they lie superficially. They are 
found in the neck, behind the ears, in the armpits, epitrochlear 
region, groin, and even in the popliteal spaces. They neither break 
down nor become matted and, precisely like the regional adenopathies 
satellite to the chancre, they feel like a rosary or string of beads. 
Their wide dissemination and symmetry reflect that of the rash 
and are similarly explicable. Fluid aspirated from the glands is 
often found to contain spirochetes. 

The visceral signs are thoracic and abdominal. Endocarditis and 
myocarditis are rare, and secondary pulmonic changes are not known. 
The abdominal viscera affected are the liver, spleen and kidneys. 
With, and sometimes without icterus or jaundice, hepatitis 
occurs, with enlargement of the liver demonstrable by percussion 
and palpation. The spleen is frequently enlarged and in febrile 
cases typhus, typhoid and atypical forms of malaria are simulated. 
The Widal reaction is absent, blood cultures for the typhoid and 
typhus bacilli are negative, and plasmodia are not demonstrable. 
On the other hand, aspirated blood from the spleen contains spiro- 
chetes. The signs of syphilitic secondary nephritis are those of any 
acute or subacute parenchymatous inflammation of the kidney. 
Whether the alimentary tracts and pancreas may be involved is not 
yet known. 

In syphilitic periostitis or osteitis the bones are tender and the 
periosteum is roughened. This is particularly the case along the 
anterior tibial margin, the site of election, but other bones are at 
times involved, and with fever acute osteomyelitis is simulated. 
Clinical evidence of peripheral circulatory changes are virtually un- 



404 DERMATOLOGY 

known although anatomic vascular changes are common in the second- 
ary stage. 

Central nerve involvement occurs as mild swelling of the 
arachnoid causing headache and, in a substantial majority of in- 
stances, changes are observed in the cerebrospinal fluid, the Wasser- 
mann reaction, pleocytosis and globulin reaction sometimes being 
present. True meningitis, encephalitis and myelitis are rare indeed. 
The optic nerve is involved in almost twenty percent, of all cases of 
secondary syphilis, as ophthalmic examination shows. Early blind- 
ness occurs, although rarely, the second nerve either spontaneously 
or under proper treatment usually showing a perfect recuperative 
ability. Even more rarely the auditory branch of the eighth nerve 
is involved, but permanent deafness is most unusual. Bone con- 
ductivity is diminished. Seventh nerve palsy too, is rare. The 
other special nerves are not known to be involved, but mild peripheral 
neuritis is not entirely uncommon, and this must explain the pain in 
the extremities, otherwise partly explained by myalgia and arthralgia. 

The humoral changes are those already indicated in the lymph 
glands, spleen and cerebrospinal fluid. More important is the 
Wassermann reaction in the blood which is present in practically 
all cases of secondary syphilis. Thus this test is of such great 
corroborative significance that it may well be regarded as a cardinal 
sign of syphilis in the invasive stage. 

Course. Untreated, the course of secondary syphilis runs from 
six months to two or three years, spontaneously disappearing as 
tertianism develops. Barely the entire disease stops in that stage. 
Treated cases run atypical courses, depending upon the kind of 
therapy employed, and the manner of its administration. The 
untreated secondary stage progresses in augmenting and receding 
waves of clinical and serological manifestations. At one time the 
rash has one quality, at another, another. Likewise, the other 
symptoms and signs vary, depending upon the virulence of the 
infecting organism, its strain, and the reaction thereto of the host. 
But the striking feature is remission and recrudescence, the former 
representing transitory latency, a term more useful than scientific. 

Although all the foregoing is absolutely essential to a broad grasp 
of secondary syphilis, the dermatologist must more minutely master 
its cutaneous manifestations with especial reference to differential 
diagnosis. Eor this reason, under the appended heading of varieties, 
which applies to the rash on the skin and mucous surfaces, this 
aspect of the subject will be covered. 



ACQUIRED SYPHILIS. THE SECONDARY STAGE 405 

VARIETIES OF SECONDARY SYPHILITIC ERUPTIONS 

Macular Syphiloderm (Fig. 84). The macular syphiloderm, 
also called the syphilitic roseola, is an eruption consisting of erythe- 
matous spots at the sites common to all secondary eruptions. It usu- 
ally begins on the front or back of the torso as an eruption of delicate 
rose colored macules about one centimeter in diameter. These are 
either so pale as to be almost invisible except in side lights, or so 
dark as to be easily visible; and the lesions may be very few or 
extremely numerous. The rash lasts from one to five weeks, usually 
having made its appearance within six weeks to three months after 
exposure, and within four weeks to two months after the appearance 
of the chancre, or within four weeks after its disappearance. 
Occasionally the rash is fugacious and consequently escapes the 
attention of both physician and patient. It does not itch and so of 
course there are no scratch marks. It may be associated with other 
types of secondary lesions but at first is apt to exist alone. 

Another form of macular syphilide is the so-called recurrent 
roseola which is a late secondary manifestation, seen as a rule six 
or eight months after the initial lesion has appeared, and which is 
the result of inadequate or no treatment. Its characteristic sites 
are the torso, but it may appear on the extremities, rather favor- 
ing the flexor surfaces but not entirely excluding the extensor. 
These lesions are somewhat larger than those of the early ros- 
eola, and inclined to be ring shaped or festooned. Recurrence of 
this type of roseola may take place at intervals if the disease is un- 
checked. 

There is a form of macular syphiloderm called by Unna the neu- 
rosyphilide which is extremely rare and which, according to this 
observer, is analogous to the ring-shaped lepra lesions on an alleged 
basis of involvement of the cutaneous nerves. It is not purely mac- 
ular, being somewhat raised and slightly infiltrated, and of a darker, 
more coppery color than that usually seen in macular syphiloderms. 
On the other hand, it is by no means so infiltrated as to suggest a pap- 
ule. All macular syphilides, although prevailingly flat, sometimes 
give the impression of being raised in the manner of a superficial 
wheal, when viewed by sidelight. Indeed, even the palpating finger 
may get a slight impression of elevation. 

Macular syphilides sometimes suggest other macular eruptions, 
notably flat urticarial lesions, the spots of erythema multiforme and 
toxic erythema, and the rash seen in typhus and typhoid fever, and 
following the use of certain drugs, notably copaiba. The first three 



406 DEKMATOLOGY 

of this group usually itch; the roseola does not as a rule, though at 
times it comes as an obstinate urticaria controlled only by anti-specific 
treatment. The typhus and typhoid rash are accompanied by the 
characteristic symptoms and serological and bacteriological evidence 
of these diseases, in contradistinction to the general clinical and sero- 
logical picture of syphilis. The copaiba rash, associated as it is with 
gonorrhea, may suggest a syphilitic macular eruption with an intra- 
urethral chancre. The absence of the Wassermann reaction and gen- 
eral glandular enlargement, the finding of gonococci in the urethral 
discharge, and the history of drug ingestion, form the only basis of 
differentiation. 

Papular Syphiloderm. Papular lesions are either large or small. 
The first are called lenticular (Fig. 85) or discoid papules, the sec- 
ond, miliary papules (Fig. 86). The first two are the commonest 
types of the secondary papular syphilide. 

The lenticular papule (Fig. 85) is situated at all the common 
sites of secondary syphilis. A lenticular papule is from one-half to 
one and one-half centimeters in diameter. It is shaped like a convex 
lens ; hence its name. It is hard to the touch, pink, buff or coppery 
in hue, and does not itch or in any other way give subjective symp- 
toms. It is often surmounted by a very superficial, thin, somewhat 
greasy looking scale, and the lesions may be sparse or very numerous 
but discrete, or so numerous as to be coalescent or confluent, in 
which event they form figures of all sorts imparting a variegated 
appearance to the skin. These lesions may be combined with the 
early roseola, or with small papules, or both, and they appear at 
about the same time that the roseola does, and run a similar course. 
Occasionally it will be found that a lenticular papule of striking 
dimensions is surrounded by small lenticular papules or miliary 
papules or both, as the sun is surrounded by its planetary system. 
These constellations give the picture of the corymbose or corym- 
biform syphilide. 

Eruptions consisting mainly of lenticular papules simulate papular 
seborrhea, pityriasis rosea, and psoriasis guttata. The character- 
istic features of secondary syphilis form the basis of differentiation. 
Objectively they differ from seborrhea in site and in the character 
of the scaling and infiltration. The site of seborrhea is in the body 
folds, over the sternum, between the shoulder blades, and on the 
scalp. The scales are heavy and greasy, the color is buff. Papular 
syphilides in a seborrheal patient, however, may assume many of 
the characteristics of seborrhea, and in these cases, without consid- 



ACQUIRED SYPHILIS. THE SECONDAKY STAGE 407 

ering the general features of syphilis, a differentiation would be 
hard indeed. 

Pityriasis rosea is usually limited to the area between the collar- 
bones and upper third of the thighs, and is preceded by a charac- 
teristic herald spot. Moreover this disease is more or less pruritic. 
The lesions of psoriasis may be numerous and as infiltrated as those 
of papular syphilis, but the scales are a shimmering white, the locali- 
zation on the whole favors the extensor surfaces, and there are no 
general glandular enlargements or any of the other signs of syphilis. 
Excepting in acute cases of psoriasis the long history of the disease is 
of diagnostic value. 

In this connection, some emphasis must be laid upon the fact 
that secondary syphilides have certain characteristic features in cer- 
tain localities. This is particularly true of the lenticular papular 
lesion. When the face is involved, although no part is free, the 
lesions tend to group themselves in a band just across the forehead 
immediately below the hair line, roughly simulating a crown or 
diadem. This is called the corona Veneris. Dr. Trimble of New 
York has called attention to the frequency with which lesions on 
the chin give an impression of mottling. On the palms and soles the 
papules appear as macules because the epidermis is so thick that the 
infiltrate is rarely able to develop the elevation seen elsewhere. 

The palmar syphilide (Fig. 90) is of great diagnostic importance 
for none of the lesions simulating this stage of syphilis occur on the 
palm excepting those of psoriasis, and this so rarely as to be negligible. 

The discoid syphilide, better known as the flat condyloma or 
moist papule (Fig. 89), has already been mentioned earlier in this 
chapter. This occurs in all body folds and on the mucous surfaces of 
the genitalia and anus as fleshy, elevated, gray, discrete lesions, or 
highly confluent masses which easily bleed, give off a foul secretion, 
and which are highly infectious. They rarely exist alone, but usually 
in conjunction with either the macular or papular syphilide, but may 
come and go throughout the secondary stage. The only condition 
they simulate is pemphigus vegetans, the lesions of which occur at the 
same sites and which have the same foul odor. In pemphigus 
vegetans there is a bullous eruption on the skin, there are no general 
glandular enlargements, and the Wassermann reaction is absent. 
In flat condylomata there are no bullae on the skin, but other forms 
of syphilides, and enlarged glands, and the Wassermann reaction is 
present. Isolated, or very few flat condylomata may simulate the 
solitary or multiple chancre. The condyloma is softer than the 



408 DERMATOLOGY 

chancre, however, and vegetating rather than ulcerating or papular. 
Spirochetes are found by the ultra microscope, in flat condylomas. 

The miliary or acuminate papule (Fig. 86), sometimes 
called lichen syphiliticus, is a comparatively rare lesion. It more 
frequently itches than any other syphilide, but even here pruritis is 
rare excepting in negroes. The entire body is studded with minute 
coppery or ham-colored discrete or grouped papules, one millimeter 
or two in diameter, sometimes slightly scaling and closely resembling 
lichen planus or lichen scrofulosorum. They too may be corymbi- 
f orm in arrangement. Lichen scrofulosorum, however, occurs mostly 
in the young and is a tuberculous process. Lichen planus itches in- 
tensely. In both of these conditions the positive evidences of syph- 
ilis, so often emphasized, are absent. 

The characteristic features, then, of the papular secondary syph- 
ilide are the wide dissemination and symmetry ; the infiltration ; the 
constant association with evidences of a disseminated and universal 
infection; the ability shown to mimic other diseases, which on the 
whole, however, can be easily differentiated; and the fact that the 
different types of papules may occur simultaneously and may also 
be associated with the macular eruption. When this occurs, and 
the occurrence is very common, the eruption is described as maculo- 
papular. 

The annular syphilide. At times, and particularly in negroes 
(Fig. 87), although occasionally in whites, papules arrange them- 
selves in rings on the face, neck, and less commonly elsewhere on the 
body. These rings may be few in number or numerous and their 
segments describe arcs of various degrees so that small circles the 
size of a dime may be seen, or segments which if completed would 
represent circles ten inches in diameter. At times the circles are 
concentric. For the most part the papules composing these figures 
are closely grouped and miliary. It is possible for these lesions to 
simulate ringworm, but the diagnosis can easily be cleared by a 
search for fungi versus a search for other evidences of syphilis, and 
the performance of the Wassermann test. 

In discussing seborrhea in a preceding paragraph it was stated 
that syphilides in seborrheal patients often assume many of the 
features of the milder disease. This is partially so in connection 
with lesions appearing in the nasolabial folds. A delicate annular 
or crescentic arrangement of pink, greasy, scaling papules corre- 
sponding to the curve of the nostril is not uncommonly observed, and 
if it were not for the marked infiltration and the peculiar coppery 



ACQUIRED SYPHILIS. THE SECONDARY STAGE 409 

hue, familiar to the experienced eye, the condition might easily pass 
as seborrhea. Patients presenting this picture should be carefully 
studied from the standpoint of syphilis, a point which is particularly 
emphasized by Jadassohn. Usually the Wassermann reaction will 
be positive in such people. 

The Pustular Syphilides are comparatively rare and are divided 
into three groups : the acuminate, the obtuse, and the ecthymatous. 
Before describing them, it might clarify the subject to mention a few 
of the general characteristics of early, pustular, syphilitic lesions. 
Actually the syphilitic lesion, however small, is always granulo- 
matous. Sometimes necrosis occurs even in the early stage, and, 
according to whether this process is chiefly serous or serous with a 
high content of leucocytes, the lesions become vesicular or pustular. 
In the latter event, different types of pyogenic lesions are simulated, 
albeit the contents of an unruptured pustular syphilide are sterile. 
The ruptured ones become secondarily infected with the ordinary 
organisms of the skin, but these organisms play no integral part in 
the causation of the pustules. Actually, then, the vesicular and 
pustular syphilides may be considered together, the process being 
one of fluidification of the lesion, the type of fluid depending upon 
whether there are more or less of the infiltrating leucocytes washed 
off into the fluid. The pustular lesions may be small, large or ul- 
cerative. 

The small lesions correspond to those which were designated 
acuminate in the preceding paragraph. They are very rare. They 
develop as a softening stage of the miliary papule otherwise known 
as lichen syphiliticus, and constitute the picture called acne syph- 
ilitica. 

Acne syphilitica is seen for the most part in negroes. It occurs 
wherever lichen syphiliticus may. The lesions are hard and have 
a papular base surmounted by a white point such as one observes in 
acne, and if analyzed two elements can be observed, a papular base 
and a vesicular or pustular apex. In the former event the apex is 
translucent, yellowish and glistening; in the latter it is opaque and 
white or cream colored. In either case the apex is minute. The 
lesions are discrete or coalescent and heal, as a rule, without scar 
formation, though slight superficial scars may occur. As a rule 
this type of lesion exists alone, but it may be intermingled with 
miliary papules particularly, and with any other type of secondary 
syphilide in any combination. There is no itching, excepting in 
negroes, and hence in Caucasians there are no scratch marks. The 



410 DERMATOLOGY 

The other symptoms and signs of secondary syphilis are present and 
this form of syphilide is peculiarly slow in responding to treatment. 

The varicelliform syphilide. One form of the vesicular stage 
of this condition sometimes resembles varicella and is known as the 
varicelliform syphilide. It differs from varicella, however, in its 
slow evolution, in the great number of lesions, much less marked 
tendency to umbilication and in its association with all the other 
evidences of early syphilis. Vesicular syphilis may conceivably 
be confused with universal acute dermatitis. The lack of itching, 
however, and the marked difference in the symptoms and signs of the 
two diseases render it only academically necessary to mention the 
fact. 

The pustular phases resemble variola, ordinary acne, suppura- 
tive folliculitis and the pustular bromodermas and iododermas. 
Variola may be ruled out by the fact that the syphiloderms are 
smaller, the general symptoms not severe, and by the other methods 
that would be employed in an effort to recognize syphilis. Acne is 
excluded by the fact that pustular syphilides are distributed all over 
the body and that there are no comedones, whereas simple acne is 
limited to the face, chest and interscapular region. Inasmuch, how- 
ever, as acne may be present in a syphilitic, it is not always easy to 
determine which disease is represented by a given lesion, nor is it 
very important to do so, because of the mildness of the ordinary acne. 
The bromide and iodide eruptions may closely simulate pustular 
syphilides, and so far as the iodide eruption is concerned the matter 
is of some importance inasmuch as the iodides are so frequently 
used in treating syphilis. 

The obtuse pustular syphilide is to the large lenticular papule 
what the acuminate pustular syphilide is to the miliary papule. 
In other words, the liquification takes place over a somewhat larger 
surface than in the smaller form and, as in the latter, there is a 
serous and a purulent phase. The significance of these phases, 
however, is identical with those in the smaller form. The lesions 
when analyzed consist of an infiltrative base surmounted by a sac 
containing serum or pus. The lesion most simulated is the 
ecthymatous bleb. This form, too, is uncommon, but is not ex- 
actly rare. The lesions are seen wherever ordinary papules would 
appear and variola, ecthyma and the iodide and bromide eruptions 
are simulated. The differentiation among these conditions is made 
along the lines indicated above. 

Whenever any vesicular or pustular syphiloderm dries a crust is 



ACQUIRED SYPHILIS. THE SECONDAKY STAGE 411 

formed precisely as when any other skin lesion, consisting largely 
of fluid, dries. Usually the crusts fall off and the integument returns 
to normal, particularly when treatment has been started early enough. 

Sometimes, however, ulceration takes place beneath the crusts, 
furnishing the picture of ecthymatous syphilis, and we find admixed 
with other syphilitic lesions superficial ulcers varying in size from 
a millet seed to a dime or perhaps a trifle larger, the bases of which 
are infiltrated, the infiltration being cupped out by a shallow con- 
cavity that is pink, glistening and moist when the crust has been 
removed. Ecthyma and impetigo contagiosa are thus very closely 
mimicked, but in these two diseases the infiltration is less marked 
than in syphilis and the other manifestations of syphilis are wanting. 
Sometimes, before crusting takes place a veritable bulla forms. In 
this event pemphigus vulgaris is remotely simulated, but in pem- 
phigus there is no infiltration and the classical concomitant signs of 
syphilis are absent. 

Malignant Syphilis. At times, early syphilis runs a very rapid 
course and almost before the usual evidences of the secondary 
syphilitic stage are evolved the condition approximates tertianism. 
In these cases, fortunately rare because they are justifiably called 
malignant syphilis, the patient has a widely disseminated pustu- 
loecthymatous eruption, the main features of which are irregular 
ulcers of various sizes resembling tertiary ulcers and rupial 
syphilides, which will be described in the next chapter. Malignant 
syphilis nowadays is getting even less common than formerly because 
of our ability to control the disease early by adequate treatment. 
Curiously enough, in malignant syphilis the Wassermann reaction is 
often absent. Nothing else, excepting perhaps pemphigus, resembles 
this form, and in pemphigus there is very much less infiltration than 
one finds in the lesions of syphilis. Without adequate treatment, 
and in patients who are intolerant of arsphenamin or of mercury or of 
both, malignant syphilis often ends fatally, the entire course con- 
suming six months or a year. Death is due to cachexia. 

Pigmentary Syphilides. Only one more type of early syphilis 
remains to be described, namely the pigmentary syphilides. With 
one exception these syphilides are unimportant. This exception is 
known as the leucoderma syphilitica. It is usually situated on the 
nape of the neck, extending thence down over the shoulder and 
sometimes even over the breast, or upward over the cheeks and 
temples, or forward over the throat. It is exceptional to find it in 
men, and in women it is restricted largely to brunettes. The char- 



412 DERMATOLOGY 

acteristic feature of these lesions is that they impart a mottled 
appearance of white macules lying on an otherwise hyperpigmented 
integmnent. The hyperpigmentation may merely consist of a 
slightly increased buff or brown hue exaggerated by the whiteness of 
the spots within, or the hue may be somewhat like that of milk 
chocolate. Any shade may exist between the two extremes. This 
type of lesion appears from four to six months after the original 
infection and persists for years after all other evidences of the 
disease have vanished. It may be permanent. As a rule, however, 
particularly shortly after its appearance, other evidences of syphilis 
are noted. It is not safe to be arbitrary in diagnosticating the con- 
dition, for the curious mottling which characterizes it is sometimes 
seen in summer in sun tanned women who have worn lace collars or 
yokes, but who have not syphilis, the configuration being due to the 
design of the lace. In the majority of instances in which the 
pigmentary syphilides are found the Wassermann reaction is present. 
It is possible, too, to confuse the pigmentary syphilide with vitiligo 
(Chapter XVIII), or with pigmentary lepra (Chapter XXV). In 
vitiligo the white blotches are enormous, irregular, symmetrical 
and distributed, in extreme cases, all over the body. In lepra there 
are other evidences of this disease. It is theoretically possible to 
confuse the pigmentary syphilide with nevus anemicus and white- 
spot disease, or with any of the numerous pigmentary atrophies. 
Though it is scarcely worth while to discuss these matters in great 
detail, the syphilitic leucoderma represents a disturbance in the 
pigment forming mechanism, analogous to what occurs in vitiligo, 
namely an ability on the part of the tissue to produce pigment in 
certain spots with a real or fancied accumulation of pigment at their 
periphery. Whether this disturbance is local, or whether the 
chromaffin system is affected is not known. Treatment does not 
affect the lesions for, as has been stated, sometimes they are per- 
sistent, and at best it takes a number of years for them to dis- 
appear. 

Regional Peculiarities. A description of secondary syphilides 
would not be complete without some emphasis being laid on their 
regional peculiarities. The hair and nails are often affected. When 
macules or papules involve the scalp the hair often falls out at the 
site of the lesion and thus small bald patches develop, irregular in 
size, and imparting a mangy or motheaten appearance to the scalp 
as a whole. These patches are not as circumscribed as in alopecia 
areata (Chapter XXXIV) nor do they contain fungi as in ring- 



ACQUIRED SYPHILIS. THE SECONDARY STAGE 413 

worm of the scalp (Chapter XXII). The nails are either ridged, 
opaque or brittle and suggest the condition found in ringworm or 
favus (Chapter XXII), or in psoriasis (Chapter XI), or dermatitis 
involving the nail bed (Chapter IX). Other evidences of these 
various diseases being absent syphilis may readily be recognized 
when concomitant signs of the latter are present. But there are 
vague nail dystrophies which cannot easily be differentiated from 
nail syphilis. 

The face may be invaded by the macular, papular, serborrheal, 
psoriasiform, vesicular, pustular and ulcerative syphilides. The 
most common of these are the simple macular or maculopapular. 
The former causes a peculiar mottling of the chin, the latter, among 
other things, tends to form as a band at the hairline of the forehead 
giving the picture of the syphilitic crown known as the corona 
Veneris. As already mentioned the seborrheal forms favor the 
nasolabial folds. The torso and extremities may be invaded by any 
type of syphilide, the most common, of course, being the macular 
and maculopapular. The palms and soles are peculiarly liable to 
exhibit syphilitic lesions and these are usually macular or papular 
and often cause marked scaling, so that sometimes either the picture 
of palmar and plantar psoriasis, or palmar and plantar scaling der- 
matitis are simulated. Palmar and plantar psoriasis, however, are 
so rare that for practical purposes they may be considered as almost 
non-existent. Scaling dermatitis of these regions is not rare but 
usually itches intensely, while syphilis does not. Between the toes, 
particularly in people who perspire freely, maceration of the lesions 
often leads to their fungation and to the forming of flat condylomas. 
The various mucous lesions and lesions of mucocutaneous junctions 
have already been amply described, and it is here necessary only to 
re-emphasize that they should be carefully studied by the 
syphilographer because they so often give a clue to the diagnosis. 

Secondary syphilis, then, represents a systemic infection in which 
the pathogenic agents are widely disseminated and in which some of 
the most characteristic signs of the disease are found in the skin, 
and mucous membranes. Adequately to describe these objective 
signs would require a volume in itself and only the salient features 
have here been touched upon. Actually, there is no skin condition, 
however common or however rare, that cannot be aped by this ver- 
satile disease. It is always possible, nevertheless, by considering 
the general characteristics of the malady, the Wassermann reaction, 
etc., to reach a diagnosis. 



414 DERMATOLOGY 

The treatment of secondary syphilis will be discussed in a 
separate chapter. 

Prognosis. The prognosis is good, as a rule, so far as our ability 
is concerned to cause the lesions to disappear. Whether the patient 
shall be cured or not depends particularly upon how early treatment 
is begun and also upon the tolerance of the patient for antisyphilitic 
drugs, and probably to a large extent upon which one of the numerous 
strains of treponema pallidum he has been infected with. Undoubt- 
edly, syphilis in the secondary stage can more often be cured than 
not if we regard the question of cure not as purists but from the 
standpoint of the practical needs of society at large. 




Fig. 84. MACULAR SYPHILODERM 

This form is also called the roseola. It consists of more or less 
numerous, intensely vivid or pale pink, symmetrically distributed 
macules, a marked example being here shown. 




Fig. 85. PAPULAR SYPHILODEKU 

(Same patient as Fig. 84.) 
ISTote the large papules all over the body, the swollen in- 
guinal glands, the absence of scratch marks and scaling. 




Fig. 86. SMALL PAPULAR SYPHILODERM 

Note the wide distribution of the lesions, the minute papules 
themselves, grouped distinctly. 









Fig. 87. ANNULAR SYPHILODERM 

This unusual type of lesion is less frequently seen in whites than negroes. 
The rings consist of circles of minute papules. At times, the circles are con- 
centric; at times, segments of circles are seen. This form sometimes itches. 




MUCOUS PATCHES 



In the centre there are flat mucous patches, while near the corners 
of the lips the patches are hypertrophied. A mucous patch is simply 
a syphilitic papule of the mucosa, its peculiar attributes depending 
upon maceration incidental to local moisture. When hypertrophic, 
the lesions are flat condylomata. They are gray or white ulcers 
or elevations, and those on the genitalia and in the body folds are 
fetid. All are highly infectious. 




Fig. 89. CONDYLOMATA LATA 

These lesions are large papules because they are stimu- 
lated to overgrowth by maceration and warmth incidental 
to the physical peculiarities of the body folds. Often vege- 
tating pemphigus looks like this. 





Vf^-d 


HA 


Ife,.. .jB 7/ Mi 
S Bi f^"'~^ v " % ** 1 


H * 


B Bp^*' Jit 

? Kg 

i H - Hi 
■ BBBB 

1 




Sk 



JftG. 90. PLANTAR SYPHILODERM (SECONDARY) 

The underlying element in this type is the papule modified by the thick 
palmar or plantar epidermis. Thus marked scaling occurs. In secondary syph- 
ilis the lesions are usually bilaterally symmetrical, and roughly grouped. Ar- 
senical keratosis and squamous dermatitis must be excluded in cases of this 
sort. 



CHAPTER XLIII 

ACQUIRED SYPHILIS. THE TERTIARY STAGE OR PERIOD OF 
ATTEMPTED SELF-LIMITATION 

Syphilis must be conceived as a disease with a generous intention 
not to harm the human body too much. These good intentions, how- 
ever, are so slow in evincing themselves that permanent harm is often 
done before self-limitation has become complete. 

The recession of the disease occurs in alternating waves of recru- 
descence, and quiescence. After the secondary period is over, a 
stage of more or less pronounced latency, sometimes lasting for years, 
arrives ; and then little by little signs of activity may again be noted. 
No part of the human body may claim exemption, but usually not 
all parts of the human body are involved. In this chapter, only the 
cutaneous manifestations of the tertiary stage will be described, a 
separate chapter having been reserved for conditions affecting other 
organs and tissues. 

Before describing these cutaneous changes, however, it may be well 
to indicate the general characteristics of teritary syphilis. It has 
already been stated that the keynote of this phase of the disease is 
a marked tendency towards localization of the process, in contradis- 
tinction to the dissemination thereof, characteristic of the early 
stage. In other words, the host has tried to wall off the invader and 
has partly succeeded. At times, for biological reasons which it is 
impossible here to discuss, the immunizing power of the host is in- 
adequate and the disease lights up again, quickly to be curbed. 
Whether these phenomena, in the last analysis, depend on a variable 
degree of virulence of the invader, or on a variable degree of resis- 
tance of the host, or both, has not yet been determined. In one place 
or another in the body, however, the host reacts to the parasite by 
throwing out an inflammatory tissue wall about it. The lesion thus 
produced is a granuloma, the exciting cause of which is the 
treponema, and the significance of which is a successful tissue reac- 
tion against the organism. Investigations of Warthin of the 
University of Michigan have conclusively proven that the treponema 
is capable of lying dormant in the human tissue without exciting 

415 



416 DERMATOLOGY 

any inflammatory reaction. As a corollary to this it is presumable 
that when the tissue reaction is called forth, the host is better able 
to take care of the invader than when not. 

Be all this as it may, the striking feature of tertiary syphilis is the 
gumma. It is the appearance and disappearance of gummas that 
give us clinical evidence of tertiary syphilis. Gummas, then, are 
not likely to be numerous. They are practically never symmetrical, 
usually there are no general glandular enlargements as in secondary 
syphilis, but as a rule the Wassermann reaction is positive, although, 
according to various investigators, in from ten to forty percent, of 
the cases this may not be so. 

Gummas that involve the skin conform roughly to several fairly 
distinct types, and in general may resemble any other type of infec- 
tious or non-infectious granuloma. According to whether they are 
small lumps or scaling, or more voluminous they are termed nodular, 
squamous or gummatous. 

The Nodular Gumma may be pointed, circinate, or serpiginous. 
Whatever its sub-type it consists of groups of papules or nodules of a 
coppery color and a distinctly resistant, if not hard, feel. Some 
gummas are seen in groups the outlines of which resemble a kidney, 
fan, or horseshoe, usually indicating by their contour their origin at 
a fixed point from which they spread forward and laterally. If we 
regard the syphilitic granuloma as uniform in type, whether it be a 
chancre, secondary syphilide or a lesion of late syphilis, we realize 
that the life history of a single lesion in all the stages of syphilis is 
subject to the same variations. Thus the differentiation among vari- 
ous gummas, as has been done and will be done, is artificial, but for 
practical purposes necessary, because the technical language of syphil- 
ography has been accommodated to our visual impressions. 

To digress for a moment, it may well be here further emphasized 
that any type of syphilitic lesion, including a gumma, is bound to 
start with the simplest form of inflammatory reaction, namely the 
red spot, and evolve through all the gradations with which we are 
already familiar. Thus we observe the papular or nodular gumma, 
the scaling gumma, and the ulcerative gumma; and among the 
nodular gummas we find the sub-varieties already mentioned. 

To return, now, to* the description of nodular gummas for the 
moment interrupted. When gummas spread peripherally they may 
or may not heal centrally. These are called serpiginous gummas 
(Figs. 91 and 92). Thus the nodular gumma embraces any or all 
of the above characteristics. These may consist purely of group 



ACQUIEED SYPHILIS. THE TERTIAKY STAGE 417 

nodules, or of nodules grouped to form a circinate outline, or of no- 
dules not only grouped and circinate but serpiginous. If many 
such patches should develop in a comparatively restricted area they 
coalesce, and the resulting plaque possesses a festooned outline. 
A gumma, according to whether it has destroyed a great deal of tissue 
or not, leaves scars. The scarring may be preceded by ulceration, 
or acquired by destruction without visible necrosis. If there has 
been visible necrosis and ulcers form, the ulcers may be, and usually 
are crusted. The crusts form as a covering over the floor of the 
ulcer. If the margin progresses beyond the crust, there is entirely 
new crust formation, the new crust raising the older crust from be- 
low. This may go on in several layers so that the resulting lesion 
represents an ulcer surmounted by an oystershell-like covering which 
gives the picture of what is known as the rupial syphilide. Gummas 
form on any part of the body, but the face, the scalp, palm, sole, shin 
and buttocks are the sites most likely chosen. 

When a gumma consists purely of nodules one observes a plaque, 
with the outlines already described, in the form of elevations on the 
skin varying in number according to the size of the plaque, and in 
size from bare perceptibility to the diameter of a dime. According 
to the diameter and elevation the individual lesions are either pointed 
or lens shaped, surmounted by scales (squamous), or ulcerative and 
crustaceous if a crust forms. If the patch heals centrally, scars of 
various size, shape and density develop, depending upon the degree 
of preliminary necrosis. As a rule, these scars are thin and delicate 
with a rather crumpled, pliable surface suggesting paper, and are 
inclined to be brown but are sometimes devoid of pigment. The 
total area involved by such groups of lesions may be relatively small 
or extremely extensive, covering sometimes the entire buttocks, back 
or thigh. When numerous ulcers develop in such a plaque it may 
have a honeycombed appearance. If the lesions are vegetating they 
are called frambesiform. If the lesions are larger than nodules and 
more like tuberosities they are called tuberous, and according to the 
shape of the plaque and other circumstances already mentioned they 
are called tubero-ulcerative, tubero-serpiginous, tubero-circin- 
ate, or tubero-squamous. 

The Squamous Gumma may be diffuse or circinate. The basic 
element here again is the nodule, but the nodules are so compactly 
grouped, so little prone to necrosis, and with such a marked tendency 
to scaling that they are justly called squamous gummata. They too 
appear on any part of the body, are coppery and somewhat waxy 



418 DERMATOLOGY 

looking agglomerations of elementary lesions, the outline of which 
may be circinate and the progress of which may be serpiginous. In 
involuting they leave very slight if any scarring, but show a marked 
tendency to hyperpigmentation, the pigmentary patches persisting 
for long after the active process has waned. 

The Gummous or Massive Gumma (Figs. 93 and 94). The 
third major type of cutaneous gumma is the so-called gummous type 
which might perhaps better be called a syphilitic tumor, or massive 
granuloma. This sort of lesion is tumor-like in appearance, inflam- 
matory in character, and either copper colored, purple or a dusky 
red in color. These gummas too may remain intact or necrose, and 
the necrosis may form a shallow or deep ulcer which in turn may 
spread in a serpiginous manner. 

The type of ulceration common to all gummas is characterized by 
rather sharply punched out margins, not tending to be undermined, 
and a flat or slightly concave floor with or without granulation tissue, 
but always secreting a grumous or serous substance which crusts. 
These crusts have already been partly described. For the rest, they 
are adherent to the ulcer, and either a dingy brown or gray in color, 
depending upon what amount of blood or pus is admixed with 
extraneous matter entering into the composition of the final product. 
In elevating the crust bleeding occurs which is by no means profuse. 

The Subcutaneous Gumma (Figs. 93 and 94). In addition to 
cutaneous gummas, subcutaneous gummas are to be mentioned. 
These are comparatively rare and usually start in the subcutaneous 
tissue as isolated nodules or in groups of two or three, or sometimes 
in oval clumps of three or four individual lesions. They are hard 
and feel somewhat as if enlarged lymph glands were situated in the 
tissue depth, or like subcutaneous fibromata. They either involute 
without involving the skin, after having reached the size of a hazel- 
nut or small egg; or the process involves the skin which then breaks 
down after it has for a time looked like the voluminous gumma above 
described. It differs from the latter, however, in that it imparts to 
the palpating finger an obvious sensation of depth, and in that the 
skin is fixed to the infiltration below. Such gummas sometimes ex- 
tend to the deeper tissues, involving the muscles or even the bones. 

DIFFERENTIAL DIAGNOSIS 

In differentiating gummas from simulating lesions, it will be 
clearer to do so in connection with a description of gummas as modi- 
fied according to regional distribution. 



ACQUIRED SYPHILIS. THE TERTIARY STAGE 419 

Scalp. On the scalp the commonest type of gumma is the tubero- 
serpiginous, or tubero-ulcerative kind, a fan-shaped or horseshoe- 
form cluster of ulcers, crusted or not, and the hair in the affected area 
is absent. It is remotely possible to confuse these lesions with favus 
or deep impetigo. The former is eliminated by the absence of 
spores ; the latter by the presence of other evidence of syphilis, nota- 
bly the Wassermann reaction. The surviving scars cause permanent 
baldness, and the areas somewhat resemble the scars left by favus, 
lupus erythematosus and folliculitis decalvans. It is impossible 
to tell by looking at the scar which of these processes caused it. 

Lupus vulgaris of the scalp is comparatively rare. The differen- 
tiation between tuberculosis of the scalp and syphilis requires a dif- 
ferentiation between the lupus nodule and the syphilitic nodule on 
the clinical grounds already mentioned (Chapter XXV). In addi- 
tion to this, the Wassermann and tuberculin tests, and microscopic 
studies may be necessary. 

At the back of the neck, we frequently see serpiginous gummas of 
one kind or another, suggesting perhaps acne keloid (Chapter 
XXXV). In the latter condition, there are pustules rather than 
granulomas, and the ulcers are very superficial and undermined. 
Comedones are admixed with the lesions and the scars are coarse 
and voluminous as contrasted with the more pliable cicatrices of 
syphilis. 

Face. Gummas of the face are of two types. The first is the 
tubero-serpiginous or ulcerative sort, already so frequently alluded 
to, and now familiar in its clinical aspect. It tends to appear on 
the chin, temples and nasolabial folds but is by no means confined 
to these areas. The nodular types seen on the face are particularly 
prone to occur in the nasolabial folds and strongly suggest seborrhea 
or lupus vulgaris, but are differentiated from the former by the 
absence of seborrheal elements, and from the latter by the absence 
of the clinical features of the lupus nodules (Chapter XXV). On 
the nose and in the neighborhood thereof, the voluminous gumma is 
very likely to appear. While in the tumor stage it strongly resembles 
the tumor form of lupus vulgaris, sarcoid, or intumescent lupus 
erythematosus, as well as rhinoscleroma (Chapter XXIII). The 
differentiation from lupus vulgaris has already been indicated. 
Clinically, sarcoid may so closely resemble this type of gumma that 
only the microscope and the Wassermann test, properly applied, will 
serve to differentiate the two. Rhinoscleroma is characterized by 
greater hardness, less evidence of inflammation and its microscopic 



420 DERMATOLOGY 

structure. Lupus erythematosus is excluded by absence of marked 
scaling and absence of dilated blood vessels (Chapter XXY). When 
voluminous gummas of the nose ulcerate they again strongly suggest 
lupus vulgaris, but on closer study the ulceration of the latter is 
found to be more irregular, the edges are more undermined at the 
margin, there are lupus nodules, the tuberculin test is positive, the 
Wassermann test is negative, and in favorable cases the microscopic 
picture is distinct. Moreover, lupus vulgaris tends to destroy the 
tip of the nose while syphilis is prone to destroy the bridge. Thus, 
in lupus vulgaris the nose ultimately becomes a beak while in 
syphilis it becomes saddle-shaped. 

The Trunk. Gummata of the torso may be of any shape or size 
and have been described early in this chapter. It will be impossible, 
without going into too great detail, to differentiate such gummata 
from the various conditions they simulate. But it may be permis- 
sible to catalogue the more important conditions. The squamous 
variety resembles psoriasis or seborrhea. The nodular variety re- 
sembles tuberculides, tuberculous lepra, and sarcoid. The serpig- 
inous variety resembles various forms of tuberculosis. The gum- 
mous variety resembles blastomycosis, sporotrichosis, and certain non- 
specific ulcers, as well as ecthyma. The student is referred to the 
various chapters dealing with these conditions for more detailed in- 
formation. 

Palms and Soles (Fig. 95). Gummas of the palms and soles are 
tubero-squamous in character and hence resemble the various forms 
of tylosis, particularly squamous dermatitis and arsenical hyperker- 
atosis. The former represents a practical point to be dwelt upon. 
Chronic dermatitis of the palms and soles is common and usually 
associated with evidence of the disease elsewhere. The underlying 
elements are found to be vesicular and there is itching, whereas in 
syphilis there are no vesicles and no itching, but rather an under- 
lying infiltration. Moreover there is less tendency to circinate out- 
line in dermatitis than in syphilis, and the Wassermann test is nega- 
tive in the former. 

Mucosa. Gummata occur on the mucous membrane and muco- 
cutaneous surfaces in the various forms, prevailingly the ulcerative. 
On the lips the commonest type is the voluminous gumma which 
ulcerates and which most closely resembles the chancre, cancer and 
tuberculosis. The chancre is ruled out by the lack of regional 
gland enlargements, and the absence of spirochetes as well as the 
absence of possible secondary manifestations. Cancer is ruled out 



ACQUIRED SYPHILIS. THE TERTIARY STAGE 421 

by the clinical appearance (Chapter XXIII), the presence of glands 
and the microscopic appearances. Tuberculosis of the lips is rare 
and usually tubercle bacilli are present. 

Tongue. The foregoing also applies to gummata of the tongue 
and tonsil, but tertiary syphilis of the tongue as a whole deserves 
some special mention because it occurs in various types. In the first 
place, there is the so-called leucoplacia of the tongue, including the 
buccal mucosa as a whole. It is characterized by more or less ex- 
tensive pearly white, thick patches of relatively circumscribed out- 
line resembling lichen planus (Chapter XIII). In lichen planus 
there are usually, although not always, cutaneous manifestations. 
Lichen planus of the mucous membrane is furrowed and perhaps not 
so dead white as syphilitic leucoplacia. At the periphery of the 
leucoplacial patch one often sees small polygonal papules. 

The second form of syphilis of the tongue is a multiple infiltration 
of the muscle of this organ, with numerous smaller or larger gummas, 
which become fibrous and which present the picture known as inter- 
stitial glossitis. This bears a rough resemblance to the gummatous 
liver, as seen at autopsy. Such a tongue is irregular as to its sur- 
face and the mucosa is smooth and rather glossy, unless covered by 
leucoplacia. It feels hard and irregular when pressed between the 
fingers, and is painless. 

The third form of lingual tertiary syphilis is the ulcerative gum- 
matous form in which one observes two or three comparatively 
small syphilitic ulcers such as one sees on the skin. In addition to 
this it is necessary to remember that any of these three forms may 
coexist in any combination. There are no glands. Tuberculosis of 
the tongue is rare ; syphilis is comparatively common. In tubercu- 
losis it is usual to find the bacilli; in tertiary syphilitic glossitis no 
organism is found, and the Wassermann test is positive. 

In cancer of the tongue a very confused situation arises inasmuch 
as lingual syphilis predisposes to lingual cancer. The differential 
diagnosis, which is extremely important, has been described in con- 
nection with malignant epithelial neoplasms (Chapter XXVIII). 

As to gumma of the tonsil, the same generalities already mentioned 
apply, with the further circumstance that Vincent's angina may be 
simulated. In this condition the causative organisms are readily 
demonstrated, and the acuteness of the onset and the absence of the 
Wassermann reaction serve to prevent error. 

Genitalia. Gummata of the genital organs and anus are usually 
of the voluminous type suggesting tuberculosis, epithelioma and 



422 DERMATOLOGY 

primary syphilis, recognition and differentiation of which follow 
along the lines indicated in connection with gumma of the buccal 
orifices. 

Summary. To sum up, then, cutaneous and mucous gummata 
have the following characteristics : they represent granulomas which 
tend to group and ulcerate. There are no regional adenopathies. 
They heal after a period of more or less marked necrosis. The Was- 
sermann reaction is present in a substantial majority of instances. 
They resemble primarily primary syphilis, various forms of tuber- 
culosis, other infectious granulomata and epitheliomata, and must be 
differentiated from all of these conditions by the clinical and labora- 
tory methods, already alluded to. 

Tertiary syphilis as a whole is characterized by the presence of 
the cutaneous and mucous manifestations already described; by the 
presence of the Wassermann reaction ; by certain general clinical char- 
acteristics; by a tendency to the focal appearance of the disease at 
certain more or less definite points, and by a tendency to recur at 
these same points; by the absence of general symptoms in the sense 
employed in connection with secondary syphilis ; and by the involve- 
ment of the rest of the body in a definite and characteristic manner 
to be described in the next chapter. 




Fig. 91. TUBER0-SERPIG1N0US GUMMA 

There is a scar on the back where the advancing lesion has 
left its traces. At the margin of the scar are seen festooned 
groups of coalescing lesions which are tuberous and nodular 
and ulcerous. The progress of the lesions leads to the forma- 
tion of kidney shaped segments. 



4 ;. ' 


•fi ': 


1 


1 












) * 


. . 





Fig. 92. TUBERO-ULCEROUS GUMMA 

The progress of this lesion has been centrifugal. The entire area is 
scarred. The margin consists of ulcers which, on the inner aspect of the 
thigh, show kidney shaped grouping. The centre of the lesion shows 
renewed activity. Lesions of this sort often mimic tuberculosis. 




GUMMA OF THE SHIM 



Note the reniform contour of the ulcerating gumma, and the other unbroken 
lesions resembling erythema nodosum. 





Fig. 94. SOLID GUMMA 

Note the furuncular aspect of the lesions. Some ulcerate and crust, as on the left arm. 
Others resemble healing furuncles, still others are small nodules. 




Fig. 95. PALMAR SYPHILODERM (TERTIARY) 

Although usually unilateral, tertiary palmar and plantar syphilis may be bi- 
lateral. There is often distinct festooning or grouping of the lesions ; at times 
they are discrete, however, and almost non-specific in aspect. At times there is 
simply scaling, as on the right thumb. 



CHAPTER XLIV 

ACQUIRED SYPHILIS IN ITS GENERAL NON-CUTANEOUS 
MANIFESTATIONS 

Although perhaps in a work of dermatology the phases of syphilis 
herein to be discussed have no place in the academic sense, they 
must, however, he dwelt upon to give a broad view of the disease as 
a whole. Before the discovery of the Wassermann test, and before 
we were able to apply other refinements to our study of this malady 
it became customary to regard syphilis without objective manifesta- 
tions as latent. To this day we are forced to apply this term to the 
disease when no morbid evidence exists save the presence of the Was- 
sermann reaction. It is conceivable that syphilis may be dormant 
and the Wassermann reaction be negative, so that to all intents and 
purposes the disease appears to be cured. But experience teaches 
that in a substantial proportion of cases in which all clinical and sero- 
logical evidence is lacking, the disease may at a later date flare up. 
For this reason it is necessary for the syphilographer to know syph- 
ilis, not only in its cutaneous, but in its general aspects. 

The work of Warthin, already several times alluded to, indicates 
that from the standpoint of the general pathologist syphilis is an in- 
curable disease. In a practical sense it is not necessary to be so pes- 
simistic, inasmuch as we all die of something and if a man succumbs 
to the inevitable at the age of seventy-eight, say from an aortic in- 
sufficiency, it actually makes very little difference whether this car- 
diac condition was syphilitic in origin or not. Thirty years earlier 
in the individual's life this view could not be entertained and it 
would be the duty of the syphilographer to treat the patient's 
syphilis energetically. Further, it is clear from Warthin's work 
that syphilis may lie dormant in so insidious a manner as not to 
provoke any tissue reaction. In other words, the parasite is con- 
cealed within the host, ready to become active when the latter's resis- 
tance for some reason or other diminishes. There is no organ or 
system of the human body that cannot be a prey to the spirochete, but 
it is the central nervous, the cardio-vascular and the skeletal systems 
that appear to be the most vulnerable. In describing these com- 

423 



424 DERMATOLOGY 

moner as well as the rarer syphilitic diseases, it will be possible only 
to offer the briefest sketches, for the symptomatology is so complex 
and so extensive that this phase in itself would require an encyclo- 
pedia to do it justice. 

Nervous Syphilis is characterized by a group of conditions which 
depend upon whether the meninges or the central nervous axis be 
more greatly involved. If the meninges play the greater role we 
get symptoms of chronic meningitis or pachymeningitis which vary 
in intensity and character according to the localization of the maxi- 
mum degree of the process. Thus, symptoms of syphilitic spinal 
meningitis, or cerebral meningitis, or a combination thereof, will be 
produced. Closely related to the spinal forms is tabes dorsalis, 
or locomotor ataxia, which begins as a rule in the posterior roots, 
finally involving the cord more or less, particularly the tracts con- 
trolling locomotion and muscular sense. 

If the central nervous axis is involved one gets the picture of en- 
cephalitis or myelitis or general paresis. It is possible too for the 
syphilitic process to localize itself completely, either at one point in 
the cord or brain, a gumma forming giving the symptoms of brain 
or cord tumor ; or the process may run its major course in the arteries 
of the brain and cord, giving the picture of cerebral or cerbro-spinal 
endarteritis. The clean cut clinical entities are tabes and paresis, 
but these are so often associated with each other, or with vascular 
syphilis of the central nervous system, or with meningitis that it is 
almost unphilosophical to endeavor artificially to establish definite 
clinical entities. The recognition of these conditions depends partly 
upon clinical and partly upon laboratory evidence. 

It is possible to enumerate these features only briefly. In general 
it may be said that all central nerve syphilis tends to present the fol- 
lowing symptoms, viz. : the Argyll-Robertson pupil, ptosis, diplopia, 
diminution of the deep tendon reflexes, particularly the patellar, 
Romberg's sign, and various sensory disturbances. In paresis men- 
tal symptoms are superadded to these, namely, lapses of memory, 
disturbances of speech, and attacks of unconsciousness. In tabes 
lightening pains, and rheumatoid pains in the feet and calves are 
additional symptoms. In meningitis as well as in paresis there are 
intense headaches, and in the former the classical signs of that con- 
dition appear, particuarly the Babinski reaction. 

In vascular syphilis a condition closely simulating paresis, if not 
identical, arises, and if the larger vessels are involved there may 
be apoplexy. It is possible in syphilitic periosteitis of the cranial 



GENEKAL NON-CUTANEOUS MANIFESTATIONS 425 

bones forming the cerebral cavity to have the picture of epilepsy. 
In gummata, as already stated, brain or cord tumors are simulated. 

By means of special examinations further evidence of central nerve 
syphilis is detectable. Ophthalmoscopic examination often shows 
edema, inflammation, or atrophy of the 2nd nerve, and if the 
atrophy is complete there is absolute blindness. One of the early 
signs of involvement of the disc is a diminution in the color field. 
Deafness may be caused by involvement of the auditory branch of 
the 8th nerve with diminished bone conductivity. The 7th nerve 
is rarely involved, but either semilateral facial palsy or Bell's palsy 
may be encountered. Particularly in tabes, control of the bladder 
and rectum may be impaired or lost so that there is incontinence, and 
long before this stage has been reached cystoscopy may show a 
trabeculated bladder, or a loss of bladder tone with urinary reten- 
tion. 

In all of the conditions enumerated the blood Wassermann reaction 
is likely to be positive; but if it is negative an examination of the 
cerebrospinal fluid will usually show evidence of the disease except- 
ing when the process has become complete, either through self-limi- 
tation or therapy, in which case, although the scar tissue formed can 
never be rejuvenated, there is no clinical evidence of advancement 
and the cerebrospinal fluid becomes normal. 

The changes in the cerebrospinal fluid are as follows: increased 
pressure, an increase in the globulin content, the presence of the 
Wassermann reaction, increased number of leucocytes, and the pres- 
ence of the Nonne gold chloride reaction. Without entering too 
much into the refinements of this matter, be it said that the pleo- 
cytosis is likely to be smallest in tabes and greatest in syphilitic 
meningitis. The same applies to the globulin test. The gold 
chloride test is most characteristic in paresis, yielding what is known 
as the paretic curve, but this phenomenon is not universally accepted 
as being of invariable value. The Wassermann test, as well as those 
other reactions with the exceptions above stated, always indicate an 
active process in the central nervous system. It is not fair, how- 
ever, to imagine that the diagnosis can be labelled by a test tube 
reaction, for correct conclusions can be reached only by a proper and 
intelligent correlation of the laboratory and clinical findings. 

Syphilis of the peripheral and special nerves, excepting insofar 
as some of the nerves of special sense are concerned, is not very well 
understood. Undoubtedly, pressure at the point of emergence of 
nerves may determine various forms of peripheral neuritis. 



426 DERMATOLOGY 

Ocular syphilis has already been touched upon. It is usually 
associated with other conditions already mentioned, but it is possible 
for optic atrophy to be the only manifestation of central nerve 
syphilis. There may also be syphilitic retinitis. There is nothing 
further to add regarding auditory syphilis or syphilis involving the 
7th nerve. It is conceivable that syphilis may cause mental dete- 
rioration or insanity, simulating the various classical types of psychic 
disturbances, just as in paresis there are all sorts of aberrations 
even other than the classical disturbances of mentality, grandiose 
delusions and the like. Secondary to more important conditions, 
trophic disturbances may arise such as bed sores and perforating ul- 
cers of the foot in tabes. 

Although in the main nerve syphilis chronologically is a late mani- 
festation of the disease, it is not yet known whether its inception may 
not be placed early in the course. As a matter of fact, in a certain 
proportion of early cases changes in the cerebrospinal fluid have 
been noted, particularly the presence of the Wassermann reaction, the 
globulin reaction, and pleocytosis. Whether this may not be really 
a transitory change in the pia and arachnoid is not yet definitely 
settled, but it would seem as though, even at this early stage, sub- 
stantial changes occur in the nervous system due to the presence of 
spirochetes causing symptoms chiefly referable to meningeal inflam- 
mation, and changes perhaps permanent. In support of this point 
of view it has been noted that the optic nerve is swollen in about two 
percent, of all cases of secondary syphilis, and in a fair proportion 
of cases there is transitory and rarely ever permanent deafness due to 
auditory nerve involvement. The author has observed an intractable 
meningitis develop in a patient while under intensive modern treat- 
ment for secondary syphilis, and a second case in which Bell's 
palsy developed during this stage. 

Cardiovascular syphilis may arbitrarily be divided into syphilis 
of the heart and of the blood vessels. Myocarditis and aortic in- 
sufficiency are the commonest of these conditions, but there may be 
gummas of the heart wall and, occasionally, if such lesion localizes 
itself unfortunately, arrhythmia is noted ; or if the bundle of His is 
involved symptoms referable thereto are observed. Xearly all cases 
of aortic insufficiency are syphilitic in origin, and the majority of 
cases of chronic myocarditis in the adult are due to the same cause. 
The vascular disturbances, aortitis, aortic aneurysm and arterio- 
sclerosis or atheroma, particularly in the young, are almost entirely 
of syphilitic origin. The coronary arteries are peculiarly vulnerable, 



GENERAL NON-CUTANEOUS MANIFESTATIONS 427 

and angina pectoris is nearly always syphilitic. It is unnecessary to 
enter into the symptomatology of these conditions. Conceivably, 
many forms of acroasphyxia may be syphilitic, but so far as the 
author is concerned, he has never in a single instance been able to 
prove the fact. The work of John Stokes indicates that at least some 
forms of telangiectasia have a syphilitic basis. 

The Kidneys. Unquestionably, early syphilis may cause a paren- 
chymatous nephritis, but the majority of renal changes referable to 
specific infection are secondary to the mechanical influence of 
cardiovacular disturbances themselves syphilitic in origin. Gum- 
mata of the kidney are rare. In all of the above conditions the 
Wassermann reaction is likely to be present, and if it should not be, 
the diagnosis may be corroborated by symptomatic improvement 
under antispecific therapy. In applying this form of reasoning, 
however, it is necessary to avoid the post hoc propter hoc fallacy. 

Syphilis of the skeletal system involves the bones and joints 
either by producing periosteitis with osteitis or osteomyelitis, or by 
producing gummata, or arthritis or joint disturbance not due to local 
involvement. Periosteitis is commonest on the shin, sternum and 
bones of the cranial vault, particularly the parietal bones. Here pain- 
ful swellings, hurting most intensely at night and very tender, de- 
velop. The skin above them becomes reddened, and sometimes a 
picture resembling erythema induratum is produced. The last 
remark applies chiefly to the shins. Osteomyelitis develops mostly 
in the long bones, and mainly in the tibiae. Usually in the tertiary 
period, but sometimes in the secondary, as the result of an extinct 
local process, roughening of the anterior margin of the tibia is 
found, due to productive periosteitis. Gummata, as has been stated, 
develop mainly on the sternum and the bones of the cranial vault. 
They are often painless, and are indolent, fluctuating masses, the area 
of fluctuation being limited by a hard ring of bone. Another site 
of election for this process is at the sterno-clavicular junction. It 
must be remembered that any of the bones of the body may be 
affected. Gummata may develop at any of the large joints, and pos- 
sibly those of the sterno-clavicular type actually have their starting 
point at this joint rather than in either the shaft of the clavicle, or 
in the sternum itself. The epiphyses of long bones are peculiarly 
liable to be the starting point of this process. 

When joints are involved, and particularly when the synovial 
membrane is the starting point, an effusion takes place into the artic- 
ulation. Thus the joint swells hugely, its function is disturbed, it 



428 DEKMATOLOGY 

becomes distorted according to the extent of the hydrarthria. This 
process must be distinguished from the Charcot joint, or the second 
type of joint disturbance alluded to in the introductory sentence. 
The Charcot joint is a trophic disturbance, observed in tabes, in 
which the leg swings like a flail on the thigh, and the explanation 
of which is a disturbance of nutrition referable to the disease of 
the cord. This condition was purposely not included in the descrip- 
tion of tabes above. At times syphilis of the joints may resemble 
acute polyarticular rheumatism; this is particularly the case in 
joint disturbances during the early stages. 

The rarer general disturbances due to syphilis will be briefly 
enumerated. Syphilis of the lungs is difficult to recognize and gives 
the picture of chronic pneumonia, or of cavity formation similar to 
that observed in advanced pulmonary tuberculosis. It may be dis- 
tinguished from the latter by routine diagnostic procedures in- 
cluding the performance of the Wassermann test. Mediastinal 
syphilis is almost impossible to differentiate from mediastinal tumor 
save by means of the serum test. 

Syphilis of the abdominal viscera has not yet been closely studied. 
In the early stages the liver may be enlarged and a mild, acute 
hepatitis provoked, sometimes with jaundice and fever; while in the 
later stages multiple gummata associated with interstitial hepatitis 
may develop, or there may be syphilitic cirrhosis. Syphilis of the 
spleen in the early stages causes a, soft enlargement of this organ as 
Udo Wile points out in an excellent article written several years 
ago. In later syphilis splenetic gummata have been observed. 
Pancreatic changes are rare. The hollow viscera present changes 
in the stomach and rectum due to scarification obviously following 
ulcers of syphilitic nature. All kinds of deformities of the stomach 
have been described with their obvious symptoms and signs, and 
syphilitic proctititis of the ulcerative variety is uncommon but not 
rare. The renal changes have already been mentioned. Excepting 
for one condition, syphilis of the generative organs in both sexes 
has not yet been closely studied. This one exception is almost as im- 
portant as central nervous and cardiovascular syphilis. The testes 
are commonly involved, either by the presence of gummata or there 
are gummata of the epididymis and rarely of the cord. It is pos- 
sible, however, and this will be re-emphasized with congenital syphilis, 
that the testes harbor spirochetes without provoking any gross lesion 
clinically recognizable. A testicular gumma is a large, hard, some- 
what egg-shaped mass, not particularly sensitive, which, under favor- 



GENEKAL NON-CUTANEOUS MANIFESTATIONS 429 

able circumstances, may give rise to hydrocele of variable extent; 
and if the effusion is sufficient, the latter may conceal the former 
until after tapping. The Wassermann reaction is practically al- 
ways present and the condition responds quite readily to treatment. 
It must be differentiated from tuberculosis of the testes and malig- 
nancy by the conventional methods employed for this purpose. 

Although syphilis may involve, as has been stated, any organ in 
the body, and simulate almost any disease, it is unnecessary to go 
beyond the facts mentioned for the purpose of this book. It is 
necessary, however, to emphasize once again that the astute physician 
should be on his guard to recognize syphilis even though the Wasser- 
mann reaction be absent ; or, when present, earnestly to look for syph- 
ilis somewhere within the body. Sometimes a single enlarged gland 
will be found, and although glandular syphilis itself is rare and has 
not here been mentioned, it must be borne in mind that these organs 
too may harbor the elusive parasite. 



CHAPTER XLV 

THE MANAGEMENT OF SYPHILIS 

The treatment of syphilis to-day depends upon proper use of the 
newer synthetic arsenic compounds, in general termed arsphenamine ; 
mercury, and the iodides. The three drugs therapeutically show 
their specific properties in distinct ways. 

AESPHE^AMIN" 

Arsphenamin should not be regarded purely as an arsenical com- 
pound, but roughly as analogous to an artificially produced antibody 
capable of destroying spirochetes. Hence, it is distinctly a spiro- 
cheticide, the molecule of which is bound to the microorganism by the 
benzol ring, as an antibody is bound to antigen by amboceptor. 
What little tonic effect the arsenic might have on the host is negligible. 

Mercury may be a parasiticide, or it may stimulate immune body 
formation in the host, or it may do both. In any case there is reason 
to believe that its effect in syphilis is due as much to its influence 
on the host as on the invader. 

The mechanism by which the iodides work has not been sufficiently 
studied, but there is no doubt that the iodides are of value in the 
treatment of late syphilis. 

Arsphenamine is now represented in the market by several different 
brands made both here and abroad, and it is safe to use any variety 
licensed by the Hygienic Laboratory. It is procured from the man- 
ufacturer in ampules containing different amounts, and it should 
be dissolved and prepared very carefully according to the following 
method. 

Technic of Arsphenamin Administration. Freshly distilled 
and boiled warm water should be used. The entire contents of the 
ampule should be dissolved in this, without too violent shaking or 
manipulation. The clear yellow or brownish yellow solution is acid. 
It is dangerous to inject acid arsphenamin into the human being;- 
consequently, it is necessary to neutralize the solution. For this 
purpose a fifteen percent, sodium hydrate solution, never kept for 

430 



THE MANAGEMENT OF SYPHILIS 431 

longer than two weeks, is employed. With a sterile medicine dropper 
ten to fifteen drops are quickly put in the acid solution. A heavy 
lemon yellow precipitate forms which, upon further addition of the 
alkali, clears up. Then ten drops more of the alkali are added, turn- 
ing the drug into a disodium salt. The solution is now ready for 
use. This first stage of preparation has been in a sterile beaker 
or Florentine flask. 

We now come to the apparatus for injection. This should consist 
of a graduated tube, with a two to three hundred centimeter capacity. 
To the distal end of the container is attached rubber tubing, sterile, 
and terminating in an adapter that fits the needle to be used. Near 
the distal end of the rubber tube there should be a good clamp. The 
best type of needle, which should be sharp, sterile and patent, is that 
which is known in the trade as the Fordyce needle. About thirty 
cubic centimeters of sterile water are put into the container, and 
allowed to run through the rubber tubing, partly to flush it out and 
partly to exhaust the air, so that no bubbles get into the patient. 
About five cubic centimeters of water are allowed to remain in the 
container. A sterile glass funnel containing a sterile gauze, or cot- 
ton, or paper filter should be placed in the top of the container, and 
the arsphenamin solution should be poured from the beaker, through 
the filter into the container. Then, sterile distilled water should be 
added so that the final bulk of the solution will be twenty cubic centi- 
meters to the decigram of arsphenamine. Thus, if four decigrams 
are used, there should be eighty centimeters of fluid, etc. The 
patient is now placed recumbent on a treatment table, his arm ex- 
tended so as to flatten out the cubital fossa as much as possible, and a 
tourniquet placed about his biceps snugly enough to dilate the veins, 
but not so tight as to obstruct arterial circulation. The arm is then 
cleansed with ether or alcohol, the needle inserted, and the tourniquet 
removed. The connection with the arsphenamine apparatus is com- 
pleted, and the fluid is allowed slowly and steadily to flow into the 
veins. 

Neo-arsphenamine may be employed in a dosage half again as 
great as that of the arsphenamine. This substance is neutral and 
needs no alkalinization. It can be used in greater concentration; 
for example, four decigrams might be dissolved in fifteen or twenty 
cubic centimeters of sterile water. The question of the relative 
value of the two varieties of arsphenamine will be discussed below. 

Toxicity of Arsphenamin. As a matter of fact arsphenamin, 
if properly employed, is rarely toxic. All apparatus should be 



432 DEKMATOLOGY 

thoroughly sterilized ; the water should be freshly distilled and sterile. 
As mentioned, the sodium hydrate solution should never be more 
than two weeks old, and the solution should flow slowly. If these 
rules are observed, it is simple to employ the medicament. When 
properly tolerated, it works purely as a spirocheticide, and does 
not harm the patient. Its harmful effects, if any do appear, come 
either immediately or shortly after the injection. When they come 
immediately after the injection the symptoms roughly resemble those 
of mild anaphylactic shock, and were originally termed by Homer 
Swift " anaphylactoid reactions " and more recently nitritoid reac- 
tions. The patient complains of a sensation of pressure in the 
epigastrium and chest, the sclera becomes red, the face first red, then 
bluish, and then swollen, the respirations become shallow and rapid, 
the pulse very rapid and soft. The attack usually disappears within 
half an hour. It it a very dramatic syndrome, and one almost 
imagines that the patient cannot survive. Fortunately the phenom- 
enon is rare. It usually occurs after the third, fourth, or fifth 
injection in the series. It can be controlled by a hypodermic injec- 
tion of seven to ten minims of suprarenal gland extract, and can be 
prevented, as Stokes pointed out, by injecting 1-50 of a grain of 
atropin hypodermatically five or ten minutes before the arsphenamin 
injection, in patients in whom previous similar reactions have 
occurred. 

The delayed type of reaction takes one of several forms. The 
mildest is a sense of malaise with pain in the bones and joints sug- 
gesting influenza ; or nausea and vomiting with diarrhoea, or when 
more severe, albuminuria and suppression of urine. The last is 
extremely rare. Another form of reaction is characterized by the 
appearance of an exanthem which may be transitory and looks like 
measles or scarlet fever, or there may be a universal toxic rash 
terminating in an exfoliative dermatitis that persists for weeks, 
prostrates the patient, is accompanied by suppression of urine, or 
even with the symptoms of acute hemorrhagic nephritis, and which 
usually terminates in recovery. Hemorrhagic encephalitis has also 
been reported. The mortality after arsphenamin reactions is very 
low and, on whole, the harmful effects on the kidneys, as Schamberg 
has shown, are much less serious and much less frequent than after 
mercury injudiciously used. Serious reactions in this group develop 
anywhere from six hours to a week after the injection, and serve 
as a contra-indication to the further use of the substance. Occasion- 
ally after arsphenamin acute yellow atrophy of the liver develops 



THE MANAGEMENT OF SYPHILIS 433 

which is fatal. Occasionally, too, icterus which usually passes off 
within two or three weeks, is seen. Cases of pneumonia have been 
reported, after the use of arsphenamin, hut the reports are not clear 
and I question whether the drug ever produces this disease. Con- 
sidering the hundreds of thousands of arsphenamin injections ad- 
ministered during the past ten years, the untoward effects form so 
small a total, that the danger may be regarded as negligible. 

The cause of the reactions may be either intolerance to arsenic 
itself, or to some unknown substance in the compound, as Schamberg 
believes, or to various impurities introduced into the substance 
through careless technic, or to hypersusceptibility on the part of the 
patient to the drug. A detailed description of this matter is un- 
necessary. Neo-arsphenamin is supposed to be less toxic, and no less 
efficacious than arsphenamin. So far as my experience goes, I can 
subscribe to neither view. Injections should be made on an empty 
stomach. This in itself may prevent many reactions. 

One more type of reaction must be mentioned which has nothing 
to do with the drug, but which is elicited after any antispecific 
remedy, whether it be mercury or arsenic. This is the so-called 
Herxheimer reaction. It was noticed by this writer that in second- 
ary syphilis, after the use of mercury, (this observation antedates 
the era of arsphenamin) the cutaneous lesions stood out more dis- 
tinctly before they faded. This was explained as the result of a 
local liberation of toxins from the spirochetes following the destruc- 
tion of the latter, which increased the local hyperemia, making the 
lesions look redder. Be this as it may, antispecific remedies are 
capable of producing this phenomenon wherever there is a syphilitic 
lesion. Thus, if the phenomenon develops in or near the auditory 
nerve, or the second nerve, for example, the patient will suffer transi- 
tory partial deafness or blindness, which disappear when the treat- 
ment is continued, but which may become permanent and complete 
if the physician is frightened and interrupts treatment. It was this, 
and not the effects of arsphenamine, that produced what were for- 
merly called neurorecedives. 

Recently there has been placed on the market a permanent solu- 
tion of arsphenamin, licensed by the Hygienic Laboratory at Wash- 
ington. According to a report of Stetson at the last session of 
the American Medical Association, this substance is no more toxic, 
no less efficacious, and infinitely less troublesome to employ than the 
home made solution. Its use certainly will simplify the therapy of 
syphilis, should the hopes of its manufacturers be realized. 



434 DERMATOLOGY 

MiKRCURY 

Mercury may be used by mouth, by inunction, or by injection. 
The last method is the best. It is less efficacious by mouth than in 
any other way, and it is more irritating to the alimentary tract. The 
amount absorbed through the alimentary tract is small, and there is 
danger in making the spirochetes resistant to the drug, and rendering 
the syphilitic recalcitrant to treatment. At times there are special 
indications for its use by ingestion, and if it must be so employed, 
the best salts are the biniodides or protiodides, grains % to %, three 
to four times a day. Calomel may be used in % to *4 grain doses, 
three times a day, or bichloride of mercury, grains 1-50 to 1-10 three 
times a day. On the whole the last salts should be discarded because 
of either their cathartic or toxic effect. The best preparation for 
inunction is the United States Pharmacopoeia mercury ointment, of 
which two to four grams should be rubbed in daily for six successive 
days, each half dozen rubbings being considered a series, and one- 
half dozen series constituting a course. The surface of the skin 
should be cleansed with alcohol, and the rubbing should last one- 
half hour. Six surfaces of the body should be selected, — one-half 
of the chest one day, the other half the next day; one-half of the 
abdomen the third day, the other the fourth; the inner surface of 
one upper extremity the fifth day, and of the other the sixth day. 
After each six rubbings the patient takes a hot bath. This method 
takes times, is disagreeable to the patient and, although efficacious, 
is no better than injections. Schamberg has shown that mercury is 
absorbed through the skin. The great advantage of the method lies 
in the fact that, if the patient is intolerant to mercury, its use can 
be abandoned without any accumulation having occurred in the body, 
such as results from injections. It should never be rubbed in in 
hairy parts of the body, as it tends to cause dermatitis in these 
situations. 

Injections. When injected, mercury may be used in solution or 
in suspension, insoluble salts being employed for the latter. The 
soluble salts are the bichloride, cyanide compounds, etc. They are 
efficacious but must be used daily, or at the least every other day. 
They are painful, and my feeling is that they are less valuable than 
the insoluble salts. The insoluble salts are calomel, gray oil and 
mercury salicylate. Inasmuch as my experience has led me to be- 
lieve that calomel and the gray oil hurt more, are less easily absorbed, 
and no more efficacious than mercury salicylate, I no longer use any 



THE MANAGEMENT OF SYPHILIS 435 

but the last substance. Cole, at the last session of the American 
Medical Association, presented X-Ray photographs illustrating the 
absorption of the various insoluble salts, and proved that only the 
salicylate was freely, easily, and, regularly taken up by the body. 
The injections, which should be ten to twelve in number, should be 
begun with a one-half grain dose, which should be increased up to 
the toleration point, the intervals between the administration being 
from five to seven days. 

Toxic Effects of Mercury. The first symptom of mercury pois- 
oning is ptyalism, with swelling of the gums, and pain in the teeth. 
The next is diarrhoea. In some intolerant people, preceding either 
of these, there is albuminuria. Unless this is discovered, acute 
parenchymatous nephritis may develop. There is no reason for any 
of these things ever to happen. At the first sign of salivation the 
drug should be discontinued, or its dosage reduced. The teeth should 
be brushed with some good tooth paste or powder three times a day, 
as a matter of routine, and the mouth rinsed with some suitable mouth 
wash as often. If these measures are followed, there is very little 
danger in the use of mercury. 

IODIDES 

The use of the iodides is restricted to the treatment of tertiary 
syphilis in all its phases. From ten to one hundred grains of the 
salt should be given three times daily, in water, after meals. The 
drug seems to have a selective action on late syphilitic lesions. In 
my experience the drug is not necessary, arsphenamin and mercury 
filling all therapeutic requirements. This view, however, is by no 
means that of the majority of syphilologists, and is presented merely 
for what it is worth. As a matter of fact, very few people tolerate 
iodides well. Most of them at least develop coryza and lacrimation 
after the use of very small quantities of the drug, and nearly every- 
body sooner or later gets acne. 

THE COMBINED USE OF ARSPHENAMIN WITH OTHER ANTISYPHIEITIC 

REMEDIES 

At first it was thought that one dose of arsphenamin would cure 
any form of syphilis in any stage. It was then found that more 
than one injection was necessary. To-day we know that our hope 
for a single sterilizing dose of the drug must be abandoned. Never- 
theless, it is the best single drug available in the management of 
syphilis. Five years ago we thought that a weekly administration 



436 DERMATOLOGY 

of from four to six decigrams approximated the toxic danger point. 
To-day evidence is accumulating that it is therapeutically more effi- 
cacious, and its toxic effects not more likely to develop if adminis- 
tered every other day, or even every day for three or four days, and 
there are authorities who give small doses twice a day for three or 
four days running. If the drug is employed in inadequate quanti- 
ties, or not frequently enough injected, there is reason to believe that 
the spirochetes become resistant to it. Thus, the object of the 
treatment is to destroy the microorganisms before their own resist- 
ance to any specific remedies develops. In early cases it is safe to 
give an injection, at least every five days, for from four to six weeks, 
and to combine these injections with injections of mercury salicylate 
in the dosage mentioned above, or with inunctions of mercury. In 
late syphilis the iodides may be added, and in early syphilis there is 
no objection to the iodides. I am not yet prepared to state that a daily 
injection of arsphenamin is safe, and am here offering a scheme of 
treatment that may be employed by the average physician without 
increasing the risks of therapy to an undue point. Xo one knows 
precisely how much treatment the syphilitic needs. Thus, it is 
necessary for every physician to select for himself a standard, which 
is to be varied, according to the peculiar needs and indications of 
the individual case. In my own practice, I consider a single series 
one comprising six arsphenamine injections of four decigrams each, 
and ten mercury salicylate injections, but I have given as many 
as twenty arsphenamine injections and twenty mercury injections in 
a series, in late or obstinate cases. It is better to divide the syph- 
iliticus year into four periods — two of active treatment and two 
of rest, alternating with each other, and controlled by clinical ob- 
servation and the Wassermann test. 



THE TEEATMEyT OF THE SPECIAL PHASES OF SYPHILIS 

The Treatment of Primary Syphilis with a Negative Wasser- 
mann Test. This is the optimum time to inaugurate treatment, 
for the disease has not yet become disseminated. In a case of this 
sort, although I should personally not hesitate to give the patient a 
daily injection of four decigrams of salvarsan for five days running. I 
should not recommend such tenets to a novice. But it would be safe 
to give four decigrams every four or five days until from six to ten 
injections had been given. Combined with this, a mercury injection 
should be given every five to seven days. This course should be re- 



THE MANAGEMENT OF SYPHILIS 437 

peated after a rest period of two or three months, the physician watch- 
ing the clinical symptoms, the Wassermann test, and the kidneys of 
the patient. If the Wassermann reaction does not develop during the 
first year, the patient should receive two series of mercury injections 
a year, for two years longer, before being discharged as cured. The 
group of patients mentioned in this paragraph are amenable to abor- 
tion of the attack. 

Primary Syphilis with a Positive Wassermann Test. The 
chances of a patient in this stage of the disease are but slightly worse 
than in the phase mentioned above, and the treatment is almost the 
same, save that arsphenamine should be given in conjunction with 
the mercury for two years, instead of one. 

Early Secondary Syphilis. The infection is here disseminated 
and theoretically more difficult to eradicate than in the above groups. 
Nevertheless, the majority of patients presenting this form of the 
disease are readily amenable to treatment, which should be carried 
out precisely as in the immediately preceding paragraph. 

Late Secondary Syphilis. Here, although the infection is dis- 
seminated, it approximates the qualities of tertianism, and although 
the individual series may be modelled after the foregoing, my own 
experience leads me to counsel eight to twelve injections of arsphen- 
amin, and as many mercury injections to the series, carried over a 
period of two to two and a half years, or longer, according to the 
behavior of the Wassermann test. 

Tertiary Cutaneous Syphilis. Here the same principles are ap- 
plied that were elaborated in the last paragraph. 

Visceral Syphilis. In principle, visceral syphilis is tertiary 
syphilis, and the therapeutic indications for the various types of 
visceral syphilis conform to those included in the foregoing passages. 
Special points in the management of visceral syphilis require special 
mention. 

Syphilis of the Cardiovascular System. In treating syphilitic 
aortitis, it must be remembered that the too sudden resolution of a 
syphilitic lesion in the wall of an important vessel may conceivably 
lead to a rupture of the latter. This also holds in aneurism of the 
aorta, and other major vessels. Therefore, it may never be advisable 
to use arsphenamin, partly because of the danger mentioned, and 
partly because the introduction of a large volume of fluid into an 
overtaxed circulatory system may harm the patient. Therefore, 
treatment should be begun with small doses of mercury, extending 
over three or four months, before arsphenamin treatment is thought 



- ^ DERMATOLOGY 

of. In this way it may be possible to cause the development of a 
rnciently strong to resist perforation. The same principles 
apply in syphilitic myocarditis and pericarditis, bnt after peri- 
carditis has resolved, provided the m lium is intact, arsphen- 
amin may safely be used. Syphilitic valvular disease is subject to 
the same theoretical laws outlined for aortitis. Angina pectoris of 
nilitic origin should also be treated according to these principles. 
If it is deemed inadvisable to employ arsphenamin on account of 
the bulk of the solution, doses of neoarsphenamin, one to three deci- 
grams, dissolved in five to ten centimeters of sterile water, may safely 
be used once a week, intravenously, provided that there be reasonable 
certainty that there will be no mass 'resolution of active svphilitic 
lesions. The management of these cases requires the greatest tact 
and cooperation between a good internist and a good syphilologist. 

Syphilis of the Kidneys. In the early stages of syphilis, there 
is sometimes a cloudy swelling of the renal parenchyma, which of 
course is accompanied by albuminuria. This is not syphil:- ::■ 
nephritis, and usually the symptoms clear up under arsphenamin 
which is an infinitely safer drug to use under these conditions than 
mercury. Substantially the same is true of acute syphilitic nephritis. 
A^ error commonly made is the interruption of all treatment 
Treatmen: is "iien begun with mercury and the patient gets worse. 
This is due to an unsound belief, entertained by many, that arsphen- 
amin is less well tolerated by the kidney than is mercury, for the 
drug that should not be used is the latter. In late kidney changes 
lependent upon syphilis a weekly injection of arsphenamin, in a 
dose of three decigrams, should be given for eight or twelve weeks, 
and mercury should be used in small doses, or not at all until the 
renal symptoms are ameliorated. If there are symptoms of uremia, 
no antisvphilitic treatment should be begun until the svstemic mani- 
fr nations dependent upon disturbed renal function have disappeared, 
or until the signs of hypertension have lessened. 

Treatment of Syphilis of the Lung. Sometimes syphilis of the 
lung can be recognized. In such cases, it is safe to treat the patient 
with small, weekly doses of arsphenamin and large weekly doses 
of mercury. TThen pulmonary syphilis and tuberculosis co-exist, 
the later usually constitutes no contra-indication to the treatment of 
the former. 

Syphilis of the Liver. Early secondary syphilitic involvement 
of the liver usually yields very rapidly to treatment, as already out- 
lined for this stage of the disease. Icterus may develop, but usually 



THE MANAGEMENT OF SYPHILIS 439 

does not. If the icterus is definitely due to syphilis, it constitutes 
no contra-indication to the use of arsphenamin. Late hepatic syph- 
ilis, or gummata of the liver should be treated drastically, as are 
the ordinary forms of tertiary syphilis. The same holds true of the 
spleen. 

Miscellaneous Forms of Visceral Syphilis. At times the 
lymphatic glands are apparently the only organs affected. Drastic 
treatment is safe. Rarely the thyroid and parotid glands alone are 
affected. Here, too, intensive treatment may be followed with im- 
punity. 

Syphilis of the Central Nervous System. Aside from tabes, 
paresis, meningitis, and endarteritis, or a combination of these con- 
ditions, there may be gummata of the brain or of the cord, giving the 
picture of brain or cord tumor, or transverse or partial myelitis. 
The special methods of treatment vary slightly, according to the clin- 
ical condition, and it would be impossible in so short a chapter ade- 
quately to discuss the question involved. In general it is safe except- 
ing in the presence of gummata or myelitis, to give the patient a 
weekly injection of arsphenamin and a weekly injection of mercury. 
In treating gummata or myelitis, it is safer to prepare the patient 
with mercury (unless the symptoms are very urgent) in the manner 
outlined in connection with cardiovascular syphilis. In the first 
four conditions mentioned, the subdural administration of arsphen- 
amine has been practiced according to the methods advocated by 
Homer Swift, Hansen Ogilvie, Ravaut, Fordyce and others. Two 
schools have arisen : one condemning the intraspinous treatment as 
inefficacious ; the other endorsing it. 

Without wishing to participate in the debate, my own experience 
leads me to believe that extravagant claims for the value of intra- 
spinous treatment are as vain as the equally unscientific negative 
attitude of those who condemn it. There is no doubt that it does 
not always work, but there is equally little doubt that it has arrested 
cases, particularly of tabes in which the general treatment had failed 
to produce any beneficial results. Although the treatment should 
not be attempted by anyone but an expert, it should never be denied 
a patient with central nervous syphilis whose symptoms are not 
yielding to ordinary antisyphilitic therapy. Paresis, on the whole, 
is little influenced by any treatment, because of the peculiar path- 
ology of the condition, but tabes, meningitis, and cerebrospinal syph- 
ilitic endarteritis often yield better to a combined general and 
subdural treatment, than to the former alone. The debate has been 



440 DEKMATOLOGY 

carried on with considerable venom by antagonists to the method, 
and although their theoretical arguments are all quite as sound as the 
theoretical arguments of those who favor the treatment, the practical 
fact remains that there is something active and constructive about 
subdural therapy, even though its actual value may appear to some 
as inconsequent as the efforts of a drowning man to catch at straws. 

In treating syphilis of the auditory nerve and the optic nerve the 
results depend largely upon the extent of involvement. Often pro- 
gressive advance and blindness may be halted by intravenous and 
intraspinous therapy, and in my own experience I have seen a con- 
tracting color field expand after intraspinous therapy was begun, 
although it had progressively contracted under general therapy alone. 

Syphilis of the Bone and Periosteum. The periosteum of the 
tibia, the sternoclavicular junction, the small bones of the nose and 
the flat bones of the skull, are liable, in adults, to attacks by the spir- 
ochetes, forming osteoperiosteal gummata. In congenital syph- 
ilitics, and in children, these structures as well as the phalanges are 
susceptible, but no bones are immune. In the very young, too, the 
epiphyses of all long bones are highly susceptible. In secondary 
syphilis there is very commonly periostitis of the tibiae. All of these 
forms can safely be treated by the methods already outlined with 
reference to the stage and phase of the disease with which the bony 
involvement is associated. Very often, too, actual syphilis of var- 
ious articulations, particularly that of the knee, is encountered. 
Here, too, the therapeutic indications correspond to what has been 
mentioned. There is more danger from under treatment than over 
treatment in these patients. 

Congenital Syphilis. Newborn babies with syphilis are best 
treated with inunctions, and the substance best tolerated is the 
United States Pharmacopoeia ten percent, ammoniated mercury 
salve, rubbed in according to the instructions outlined in connection 
with inunctions. When the baby is six to ten weeks old small doses 
of neo-arsphenamin may be injected into the jugular vein, once a 
week, in doses of from one-half to one and one-half decigrams. As 
the baby grows older, the dosage may be increased, and in congenital 
syphilitics of from five to ten years of age, two to three decigrams of 
neo-arsphenamin may safely be given intravenously, once a week, 
combined with mercury inunctions of a gram of the United States 
Pharmacopoeia mercury ointment, as outlined above for adults. Con- 
genital syphilis in older children, adolescents and adults is to be 
treated as acquired syphilis, but the outlook for cure is poor. Kera- 



THE MANAGEMENT OF SYPHILIS 441 

titis, iridocyclitis, retinitis, and optic neuritis in congenital syphilitics 
are to be treated as in adults, with mercury and arsphenamin, the 
doses varying according to the age and tolerance of the patient. 

Malignant Syphilis. Malignant syphilis, better known as pre- 
cocious syphilis, is rarely seen now-a-days. It is characterized by a 
tendency on the part of the disease to acquire tertiary characteristics, 
immediately after the primary stage. This may be due to peculiar 
virulence on the part of the spirochete, or a defect in the immunity 
mechanism of the host. Formerly, such cases could not be cured 
by mercury, but since the advent of arsphenamin they are readily 
amenable to treatment, and on the whole do not terminate fatally, as 
used to be the case before this drug had been discovered. The method 
of treatment corresponds to that outlined in connection with tertiary 
cutaneous syphilis, the mercury being used as an adjuvant to the 
arsphenamin. 

Prognosis. It is infinitely easier to treat syphilis than to know 
when to stop treatment. There are rough standards, of course, but 
how reliable they are will depend upon the judgment of another gen- 
eration of observers. To-day we believe that if a syphilitic has had 
no symptoms or signs of the disease for a year without treatment, he 
is cured, and we include among the signs a persistently negative 
Wassermann test, and a normal cerebrospinal fluid. This is all very 
well, provided we know when to start the test year, and no one ever 
knows precisely when. For this reason no syphilitic, however early 
in the disease he begins his treatment, should receive less than three 
years of treatment. If, after three such years, he has had no signs 
of activity, and the laboratory manifestations are negative, it is 
safe to inaugurate the test year, but during this period the patient 
should have at least three Wassermann tests performed, and an exam- 
ination of the spinal fluid at the beginning and at the end of the 
test year. In spite of all these precautions, it is possible for so 
capricious a disease as syphilis to become active ten, or twenty, or 
thirty years after it seems to be cured. This is said without pessi- 
mism, for in the majority of instances the statement just made does 
not hold true, but it is quite impossible to state to a given patient 
that he does not belong in the smaller group in whom, after all 
due precautions, late activity may not arise. 

It has become fashionable during the past two years to scoff at 
the reliability of the Wassermann test, and academically considered, 
the Wassermann test is by no means bomb proof. It unquestionably 
may be negative in patients who subsequently show active syphilis. 



442 DERMATOLOGY 

It may even be negative at times in the presence of active syphilis, 
and it is undoubtedly positive in some non-syphilitic diseases, notably 
yaws and nodular lepra. These two diseases can easily be excluded, 
and thus, for all practical purposes, a positive Wassermann test repre- 
sents active syphilis, even though a negative Wassermann test need 
not exclude active syphilis. However, in the vast preponderance of 
cases, a negative test denotes either latency or inactivity or cure, and 
it is distinctly the duty of the physician to learn how to apply the 
negative test without condemning the entire procedure because it 
does not always corroborate his views. The Wassermann test in 
general, is the last manifestation of activity to disappear, and the 
first manifestation of activity to return, before there are frank 
clinical evidences of recrudescence. Therefore, it is a very subtle 
and, if properly used, useful symptom or sign of syphilis, and should 
be studied and understood rather than condemned by those who are 
disappointed in its apparent lack of constancy. The tendency to 
make the positive diagnosis of syphilis depend upon the Wassermann 
test is seriously to be condemned, for it is only a single manifestation 
of the disease. If this were understood, if the test were always con- 
scientiously performed by experts instead of by a great many people 
whose only claim to a knowledge of serology is their ability to pur- 
chase a laboratory equipment, the procedure would have never fallen 
into any disrepute whatever. A safe rule as to prognosis may then 
be considered a year of absence of all organic and serological evidence 
of the disease without treatment, following three years of conscien- 
tious treatment. At times the organic signs of the disease disap- 
pear, but the Wassermann test seems never to get negative. In such 
instances it is safer to give the patient two series of ten injections 
of mercury annually for an indefinite period, although it is quite 
conceivable that this may be unduly cautious, and that there 
are cases in which the Wassermann test can never be made to 
vanish. 

Marriage, and Syphilis in the Gravid. It is often trying to the 
patient and to the physician to try to decide when marriage is justi- 
fiable. Medical consent should always be withheld within three 
fears of a fresh infection, and never given at all while there are 
clinical evidences of activity, regardless of the stage of the infec- 
tion or type of the manifestations. The persistent Wassermann 
reaction in old, clinically inactive syphilis is perhaps not an adequate 
reason to insist upon celibacy, but the various problems are too 
numerous and too involved for detailed discussion in this volume. 



THE MANAGEMENT OF SYPHILIS 443 

Suffice it to say that conservatism is better than bravado. It is 
important, however, to avoid the peril of creating hypochondriacs. 

In the early months of pregnancy, in fact up to the seventh month, 
it is safe to treat the infected woman energetically according to the 
stage and character of the disease. In the later months the problem 
demands nice discrimination. In any case the kidneys should con- 
trol the indications. The earlier that treatment is begun, and the 
more energetically it is possible to pursue it, the greater the chances 
to save the baby from infection. At the confinement the placental 
blood should be collected, and a Wassermann test performed, in 
order to detect a possible congenital infection, and in the event of 
serological evidence thereof, to begin treatment before clinical evi- 
dence shows itself in the newborn. In any case the child should 
be carefully watched for symptoms or signs for ten years, both by 
physical and serological examination. 



CHAPTER XLVI 

CONGENITAL SYPHILIS i 
A SURVEY OF ITS ESSENTIALS 

The subject of congenital syphilis seems needlessly complex to 
those who have not thought about it much. It is only within recent 
years that our knowledge of this phase of the disease has undergone 
a certain degree of simplification. It is necessary merely to point 
to the historic laws of Colles and Prof eta; the disputes as to the 
source of infection, whether maternal, paternal, or both; to the old 
name, hereditary syphilis, itself, in order to illustrate the ancient 
confusion. 

On the other hand, to illustrate how this confusion is gradually 
becoming clarified, the following facts will suffice. The laws of 
Colle and Profeta have fallen. Abundant evidence exists proving 
that the apparent immunity of the mother without clinical syphilis 
to a syphilitic child, or that of a child without clinical syphilis to a 
syphilitic mother, is not immunity, but actually latent syphilis. The 
mothers and infants without clinical evidence of the disease nearly 
all give the positive Wassermann test, paralleling conditions in the 
latent stages of the acquired form. The source of congenital syphilis 
is invariably maternal, and the infection takes place through the 
placenta. This fact eliminates entirely discussion of congenital lues 
of paternal origin. The mother may have been infected by the 
father, or otherwise, but so far as the offspring is concerned, the 
source of the mother's infection is incidental. The term, hereditary 
syphilis, is unscientific and should be abandoned. It is not within 
the province of this paper to define the word hereditary, but a 
fundamental distinction exists between this expression and con- 
genital, as the works of Darwin, Romanes, Hertwig, Haeckel, or 
any other good biologist or embryologist will show. If syphilis were 
actually an inherited disease, the theory of embryonic transmission 
of acquired characteristics would need no further support. Syphilis, 
passed on from mother to offspring in utero, however, has nothing 

i This chapter is based upon " Congenital Syphilis," N. Y. Med. Journal, Sept. 
23, 1916. 

444 



CONGENITAL SYPHILIS 445 

to do with chromosomes. It is bequeathed far more simply and 
directly by actual involvement, through contact, of the placenta, and 
the invasion of the latter by the mother's spirochetes. Thereupon 
the placenta, a small participant in the mother's systemic infection, 
becomes the starting point of the disease in the fetus. 

N"o fundamental difference exists between syphilis acquired before 
birth and that acquired after birth. The disease is always the same, 
subject to variations in the virulence of the strains of spirochetes 
and the resistance of the host. Syphilis is syphilis. Any distinctive 
features the congenital form may possess, not found in the acquired 
form, are due to biological differences between the unborn and born 
human being. 

Roughly speaking, the infected placenta is the primary lesion in 
fetal syphilis. Thence the spirochetes are conveyed by means of 
the placental circulation direct into the fetal blood stream. This 
serves to disseminate the microorganisms rapidly and effectively, 
sparing no organ or tissue. The liver is the first fetal organ to re- 
ceive the placental blood, because the branches of the umbilical vein 
go direct to this organ, and because of the intimate association of 
placental and portal circulations. Thus the liver can never escape 
infection. In post-natal syphilis the entrance of the pathogenic 
agents into the blood stream is accomplished differently. From the 
primary lesion the spread of the spirochetes takes place first through 
the lymphatics. The entrance into the cardiovascular circulation 
is effected by transit of the spirochetes from the perivascular lym- 
phatics through the vessel walls into the blood stream. (Chapter 
XL.) At the moment that this is consummated, such slight differ- 
ences as there are between pre-natal and post-natal syphilis vanish. 

The month in which infection of the fetus takes place varies; if 
very early the fetus will die, become macerated, and be discharged 
before or at term ; if somewhat later, the fetus may survive and be 
born prematurely, or at the normal time, with the usual evidences 
of the disease, or as a defective, or as a monstrosity. If the infec- 
tion occurs very late, for instance in the last month of intrauterine 
life, the infant is born at term, alive or dead, and with or without 
objective evidence of syphilis. Much depends upon the type and 
stage of the mother's syphilis. Should she be the victim of a virulent 
strain of spirochetes, and in the secondary period, or a secondary 
latent period, the degree and severity of the fetal disease will prob- 
ably be greater. Should the mother have become infected in the 
fifth month of pregnancy, the fetus could not have become involved 



446 DERMATOLOGY 

in less than from two to three months, or in its seventh or eighth 
month. The later during parturition that the maternal infection 
occurs, the greater the chance of the fetus to escape the disease en- 
tirely, or to be born with earlier or milder congenital syphilis, as the 
case may be. 

It is not uncommon to obtain the following account from a woman 
married about ten years. The first child is nine years old and well. 
Shortly after the birth of this child there came three miscarriages 
in the fifth, sixth and seventh months, respectively, followed by a 
full term baby with snuffles and an eruption. This baby lived ten 
days. A year later, a normal infant was born which seemed well 
and is now five years old. Since its arrival there have been two 
stillbirths, each child having appeared normal, however, and now 
there is another baby about nine months old. It appears well, but 
" catches cold " easily, and has had a rash about the anus and lips. 
The mother herself asserts that she has always been healthy, but re- 
members that after birth of the first child she had a sore on the 
vulva and a discharge, but paid no attention to them and consulted 
no physician. Such a history is significant. The child just escaped 
syphilis. Fortunately, he was not nursed. From her second to her 
fifth pregnancies, the mother was in the secondary and secondary 
latent stages. During her sixth pregnancy the disease was in 
abeyance. An exacerbation occurred contemporaneously with the 
seventh and eighth pregnancies, resulting in stillbirths, and during 
her ninth pregnancy she was again in a latent period. The Wasser- 
mann test in this family would be positive in the mother, nega- 
tive in the first living child, either positive or negative in the second 
living child, and positive in the third. 

Thus, to recapitulate, an interplay of two factors determines the 
form that congenital syphilis assumes : first, the month of fetal life 
in which infection occurs, and, secondly, the stage of maternal syphilis 
during which transmission occurs. In addition to this, a third in- 
fluencing factor must now be included ; namely, therapy. Satisfac- 
tory treatment of the mother may prevent fetal infection. Inade- 
quate treatment may have no effect on the offspring, or may diminish 
the maternal infection and at least increase the chances of the fetus to 
escape the disease, by prolonging or intensifying the periods of the 
mothers latency. The older the mothers infection, the less the like- 
lihood of transmission to the child. Thus, in the tertiary period 
fewer syphilitics are born than in the secondary. 

Subject, too, to these factors, the symptoms and pathology of con- 



CONGENITAL SYPHILIS 447 

genital syphilis will vary. Its morbid anatomy corresponds to that 
of the acquired form. In brief, no tissue or organ is sacred to the 
spirochete, and thus the symptoms of congenital syphilis include a 
wide range of possibilities and form numerous pictures, many of 
which are well known, others rare or uncommon. In this paper only 
such features of the disease will be dealt with as are found in con- 
genital syphilitics born alive. The symptoms are in the main refer- 
able to the skin, eye, ear, liver, spleen, bones, and joints, but other 
organs are frequently involved, and commonly enough central ner- 
vous and mental disturbances, and diseases of the kidney, suprarenal 
and other ductless glands are observed, and the Wassermann test is 
positive in ninety-eight percent, of the cases. 

For the sake of simplicity and convenience congenital syphilitics 
will be divided into the following groups : 

1. Patients born with cutaneous and marked systemic evidences. 

2. Patients born with cutaneous and slight systemic evidences. 

3. Patients born with cutaneous lesions alone, subsequently mani- 
festing systemic evidences. 

4. Patients born apparently healthy, acquiring evidences of syph- 
ilis within a year. 

5. Patients born apparently healthy, acquiring evidences of syph- 
ilis between the second and seventh years. 

6. Patients born apparently healthy, acquiring evidences of syph- 
ilis after the age of seven years. This includes Fournier's group of 
delayed congenital syphilis. 

1. Patients bom with cutaneous and marked systemic evidences. 
This form denotes an infection of the fetus in about its first month 
of development. When infected so early, the fetus rarely reaches 
term alive, but if it should it presents a picture of general malde- 
velopment ; the face is drawn and gives an impression of senility. A 
papular or bullous dermatosis, the latter the so-called pemphigus 
neonatorum, covers the palms and soles. Mucous patches are present 
on the lips, in the pharynx, and on the perineum. The liver, spleen, 
and lymph nodes are found enlarged. The child nurses and cries 
feebly, and lies quietly as if palsied. This is the so-called pseudo- 
paralysis of syphilis due to specific epiphysitis and osteoperiostitis. 
The bones and joints hurt when the child moves, and are sensitive 
upon manipulation, the later eliciting a sharp cry. Usually death 
occurs shortly after birth, the cause, as a rule, being general weak- 
ness, but sometimes pneumonia. This form of pulmonary disease 
is an interstitial inflammation caused by the activity of the spirochete, 



448 DERMATOLOGY 

and known as white pneumonia, The Wassermann reaction is posi- 
tive, and spirochetes are demonstrable in the lesions on the mucous 
membrane and in the eroded papules near the body orifices. 

2. Patients born with cutaneous and slight systemic evidences. 
A macular or maculopapular eruption, with pemphigus neonatorum, 
slight or no snuffles, a certain degree of unwillingness to suckle, some 
swelling and tenderness of the bones, and even pseudoparalysis char- 
acterize this form. If the liver and spleen are not palpable at birth, 
they soon become so. The Wassermann test is positive. Unless 
treatment is begun promptly, severer symptoms set in, such as iritis 
and iridochoroiditis, and if therapy is still neglected all the general 
features of the disease appear, including permanent blindness or 
deafness, bony deformity, or even death from marasmus. 

3. Patients born with cutaneous lesions alone, subsequently mani- 
festing systemic evidences. In this form syphilis has been acquired 
in the seventh or eighth month of fetal development. Thus the 
symptoms at birth represent those of the early secondary stage. 
Only suspicious skin lesions may be present, or a frank maculopapu- 
lar rash, mucous patches, flat condylomata at the anus, or mucous 
patches in the mouth or on the genitalia. When so fully developed 
these symptoms indicate the florescent secondary stage. At times, 
however, only mucous patches are seen, or groups of papules, or cir- 
cinate papuloulcerous lesions in the perineum or elsewhere, or tuber- 
oserpiginous gummatous lesions. These symptoms are associated 
with snuffles. The Wassermann test is positive, and spirochetes 
may be found in the secretion from the mucous lesions. This form 
indicates fairly good resistance on the part of the baby, and that the 
disease is in its late secondary, or perhaps even early tertiary stage. 
Should it progress because of neglect of treatment, all the manifesta- 
tions already mentioned in the first two groups may arise. 

4. Patients born apparently healthy, acquiring evidences of syph- 
ilis within a year. At birth these infants are sound, nurse well, 
cry lustily, and thrive. Sooner or later, in seventy percent, of the 
cases between the third and eighth week, and in ten percent, of the 
cases between the third and twelfth month, mild, followed by severer 
symptoms arise. At first the infant's desire to nurse lessens, it ceases 
to gain, begins to lose in weight, cries, gets hoarse, and has snuffles. 
ISText an eruption appears similar to that noted in the previous group. 
Adenopathies develop, the digestion begins to suffer, and loss in 
weight goes on more rapidly. The crying increases and hoarseness 
grows more pronounced. Bony swelling and tenderness, keratitis, 



CONGENITAL SYPHILIS 449 

neuritis of the auditory branch of the eighth nerve may develop. 
The liver and spleen enlarge. Subject to the age of the infant and 
the intensity of the digestive disturbance, these symptoms abate or 
lead to death, unless treatment is timely. The Wassermann reaction 
is present. According to Knoepfelmacher and Lehndorf, however, 
this is not the case before the appearance of the rash. This form of 
the disease is practically always tertiary, or at least very late 
secondary. 

From this point on, congenital syphilis is invariably tertiary in 
type. The systemic evidences are not generalized, but tend to be 
selective, picking out organs in widely separated regions. The 
disease now acts precisely as does late syphilis in the acquired form. 
It develops a peculiar affinity for the bones, skin, cerebrospinal axis, 
liver, spleen, and glands. 

5. Patients born apparently healthy, acquiring evidences of syph- 
ilis between the second and seventh years. For the first years of its 
life the child develops normally, or constantly remains somewhat be- 
hind the average in physical and even mental progress, but is not 
actually ill. In the second year, it becomes indolent, makes a 
rhaehitic impression, but lacks the rosary, or it may have actual 
rickets in conjunction with syphilis. The fontanelles close slowly, 
or the cranial bones are thinned to a papery consistence in some 
areas, or thickened into bosses through periosteal infiltration in others* 
The first of these conditions is called craniotabes; the second, Par- 
rot's nodes. Instead of developing as in normal children, the bridge 
of the nose remains flat, the tip growing. Thus, this organ acquires 
the shape of a saddle, through failure to develop, or through the de- 
struction of the small bones composing its structure, chiefly the nasal 
spine of the frontal bone, the vertical plate of the ethmoid, and the 
crest of the nasal bones. As a sign of congenital syphilis the saddle 
nose possesses no value before well on in the second year, as all infants 
are more or less wanting in the nasal bridge, a fact that Knoepfel- 
macher used to emphasize to his students. But from the second year 
on, the sign is of great corroborative value. Other changes in the 
bones and joints are also significant. The long bones are peculiarly 
vulnerable, both periosteum and epiphyses being affected. Involve- 
ment of the former leads to thickening and deformity of the shaft, 
of the latter to thickening and deformity of the ends, causing the 
outlines of the joints to appear abnormal. The tibia is often bent 
forward so that its convexity is increased and the anterior margin 
is sharp but roughened. This gives it the general appearance of a 



450 DERMATOLOGY 

sabre, and on palpation the irregularities of the anterior margin and 
surfaces may be detected. Roentgenographs reveal all these changes. 
In the early stages of involvement these alterations cause pain, again 
giving the symptoms of pseudoparalysis, named after Parrot. Ten- 
sion of the muscles on the weakened scapula causes abnormalities in 
its shape, exaggerating its convexity and producing the well known 
scaphoid scapula. Gummas of the sternoclavicular junction, 
sternum, and osteoperiosteal cutaneous gummas elsewhere are fre- 
quently seen. 

The skin and mucous membranes are the site of mucous patches, 
gummas, circinate, tuberocircinate, or tuberoulcerous lesions and fis- 
sures at the mucocutaneous junctions, besides other changes already 
described. 

In the central nervous system and organs of special sense the com- 
monest symptoms are produced by meningitis, pachymeningitis, and 
hydrocephaly, but tabes, spastic paraplegia (Little's disease) and 
hemiplegia, and juvenile general paralysis are known. Some cases 
of epilepsy, mental deficiency, imbecility, and early insanity are due 
to congenital syphilis. By far the most frequent changes in the 
organs of special sense are found in the eye and ear. Keratitis, both 
interstitial and parenchymatous ; irodochoroiditis and auditory nerve 
neuritis are the commonest, but optic nerve neuritis, retinal pigmen- 
tation, and deafness due to gumma in the auditory centre, are met. 

The liver practically invariably, and the spleen somewhat less 
frequently, are enlarged, usually because of chronic interstitial in- 
flammation. At times, however, gummas may develop in the liver, 
and rarely parenchymatous hepatitis. The last mentioned condition, 
however, rare as it is, is almost unknown after the first weeks of the 
congenital syphilitic' s existence, when it causes jaundice and other 
symptoms referable to the liver. The lymphatic glands act as they 
do in late acquired syphilis. Isolated enlargements are found, with 
a relative but not constant predilection for the epitrochlears. 

6. Patients bom apparently healthy, acquiring evidences of syph- 
ilis after the age of seven years. It is from this point on, or after 
the time of the second dentition, that Hutchinson's triad, two ele- 
ments of which have already been considered, comes into prom- 
inence. The triad consists of keratitis, or scars resulting therefrom, 
deafness, or other definite evidence of eighth nerve disease, and the 
presence of Hutchinsonian teeth. The first two of these have been 
sufficiently discussed. By the term, Hutchinsonian teeth, is under- 



CONGENITAL SYPHILIS 451 

stood an alteration in the shape and position of the upper incisors 
of the second set. They converge, their distal margin is shorter 
than their base, and their edges are notched from corner to corner 
by a semilunar concavity. The corners themselves are somewhat 
blunt, and the anterior surfaces of the teeth are often ridged ver- 
tically. Although highly suggestive of congenital syphilis, this sign 
is by no means pathognomonic. Other conditions, notably rickets, 
may produce similar alterations, while syphilis itself may produce 
other varieties of dental dystrophy. In addition to the triad, in 
the retarded variety of congenital lues, all the other conditions 
enumerated in the previous group may be present, and this period 
coincides with life. The very first symptoms of the disease have 
been known to occur as late as the end of the second, or early in 
the third decade, and all changes which are characteristic of tertiary 
acquired syphilis may be found in syphilis congenita tarda. The 
Wassermann test varies according to the laws governing this phe- 
nomenon in acquired lues, but all in all it is far more likely to be 
positive than negative. 

Having described, as far as possible, congenital syphilis according 
to its picture at given ages of the patients, and in given periods of 
the disease, it will perhaps be not amiss to refer categorically to its 
common individual manifestations, and to some of the rarer ones. 

The skin lesions are in the main identical with those seen in the 
acquired form. Two points, however, merit emphasis : first, bullous 
syphiloderms are not uncommon, and are usually seen at or soon 
after birth, chiefly on the palms and soles, in the form of the so- 
called pemphigus of the newborn. Secondly, eroded papules are 
frequently found on the nates, which are of peculiar significance, 
since a nonspecific dermatosis closly simulates them. The latter is 
the erythema gluteale of Leiner, first described by Parrot, in 1877. 
It is characterized by the presence of erythematous macules, vesicles, 
or papules, and it sometimes resembles pemphigus neonatorum. The 
lesions rapidly become eroded. Jacquet, Hallopean, and Sevestre 
pointed out their nonluetic nature, Jacquet calling the vesicular 
variety erytheme vesiculeux erosif, and the eroded form syphiloide 
post-erosif. NTo spirochetes are found in the lesions and the Was- 
sermann reaction is absent. Leopold has recently reviewed this 
disease, calling it the napkin eruption, and he was able to prove con- 
clusively that it was caused by alkalies remaining in the napkins 
after washing with cheap soap, inadequately rinsed out. Gummas, 



452 DERMATOLOGY 

wrinkling of the skin, onychia, paronchia, and alopecia are often 
present. In all these congenital syphiloderms the Wassermann re- 
action is present. 

The lymphatic glands present changes not differing from those of 
acquired syphilis. Abnormalities in the testes, thymus, thyroid, 
and pancreas are rare, but in the suprarenal glands somewhat more 
frequent, causing symptoms referable to these particular organs. 
The spleen is enlarged in about sixty-two percent, of all cases at 
all ages, and the liver is increased in size almost without exception. 
Often, too, there is jaundice, and at least one form of icterus of the 
newborn is syphilitic. Usually the cause of this is interstitial hep- 
atitis, but in five percent, of the cases gummata are found at autopsy. 

Although the changes in the bones and joints have already been 
discussed, the following statistics may be of interest. Still found 
epiphysitis in twenty percent, of the cases during the first three 
months of life ; dactylitis in two percent. ; tibial periostitis and 
craniotabes in forty-seven percent. ; and synovitis and arthritis in 
seven percent. Marfan includes congenital syphilis in the causes 
of rickets. Gaucher and Levy Bing, in an analysis of 347 children 
with Pott's disease, cold abscess, and coccyditis, found that, of fifty- 
eight children in whom there was reason to suspect congenital syph- 
ilis, actual evidences thereof existed in sixty-five percent. 

Among unusual central nervous manifestations precocious tabes 
must be mentioned, encephalitis, gummas of the brain and cord, 
juvenile general paralysis of the insane, and Little's disease, while 
Mott mentions two cases of endarteritis of the circle of Willis, asso- 
ciated with pachymeningitis. He also states that seven percent, 
of all cases of epilepsy may be ascribed to congenital syphilis, and 
that hyprocephalus is also frequently due to this cause. The cere- 
brospinal fluid in these cases obviously has the same characteristics 
found in central nervous diseases caused by acquired syphilis. All 
types of mental disturbances are possible, the commonest being back- 
wardness. 

The eye, as already mentioned, shows changes in the cornea, iris, 
and retina. The iritis is often bilateral, and somewhat more fre- 
quent in girls than in boys. Atrophy of the optic nerve, and cataract 
are rare. The most common affection is interstitial keratitis. With 
the exception of auditory neuritis and otitis media, there are very 
few diseases of the ear. 

Cardiovascular and blood diseases are, on the whole, uncom- 
mon. Among these are arteriosclerosis, aortitis, myocarditis, and 



CONGENITAL SYPHILIS 453 

endocarditis. Secondary anemia is not infrequent and one form of 
hemorrhagic disease, syphilis haemorrhagica neonatorum, character- 
ized by icterus and bleeding from the mucous surfaces and umbilicus, 
is occasionally encountered. This appears to be due to parenchyma- 
tous hepatitis and is always fatal. 

The respiratory phases of the disease are Virehow's white pneu- 
monia, necrosis of the nasal septum and hard palate, frequently with 
perforation, laryngitis in fourteen percent., and snuffles in seventy 
percent, of the cases. 

The Wassermann Reaction is almost invariably present Ac- 
cording to Noguchi it is present in ninety-six percent, of all cases, 
and this author's compilation of the work of other investigators 
raises the figures to ninety-eight percent. In a very careful study 
published by Mark Reuben ninety-nine percent, were found positive 
in the early stages of the disease, and fifty percent, in the later, 
about paralleling the figures respectively in secondary and tertiary 
acquired syphilis. During active congenital syphilis the reaction is 
never absent. It is only during periods of latency and at the onset 
or waning of activity, that negative results are found. 

Summary. So concentrated an outline as this perforce had to be, 
could barely accomplish more than to sketch in the essential features 
of congenital syphilis. It is hoped, however, that several points have 
been sufficiently emphasized to eradicate its unnecessary traditional 
complexities. Congenital syphilis is syphilis acquired during intrau- 
terine life through the placenta, which after having become infected, 
plays the part of the primary lesion. From this point the umbilical 
vein conveys the spirochetes to the fetus, the liver being the first 
organ involved. Thence the spirochetes are rapidly disseminated 
throughout the fetus. Here all differences between congenital and 
acquired syphilis disappear. Subject to the month of fetal infection, 
the infant presents cutaneous and systemic evidences of the disease 
in its secondary, latent or tertiary stages, and the tertiary stage may 
be protracted for years, or tertiary changes late in adolescence, or 
early in adult life may be the first sign of the congenital infection. 
Remarkable as such facts may appear, they need cause no astonish- 
ment, for in acquired syphilis we see, frequently enough, examples 
of freedom from secondary manifestations, the first reappearance of 
activity occurring twenty years or more after the primary lesion, in 
the form of tertiary changes. These facts serve only to prove the 
identity of congenital and acquired syphilis. 

In conclusion, one more circumstance must be recorded, and this 



454 DERMATOLOGY 

depends not upon the disease, but upon the age at which the disease 
is acquired. Congenital syphilis is transmitted to its victim during 
the most important period of development, namely, before birth, and 
the struggle to overcome this burden takes place partly before, and 
partly soon after birth. Thus, aside from its actual pathological 
alterations, the disease may cause all sorts of anomalies of develop- 
ment, physical deformities and dystrophies ; and mental backward- 
ness, if not actual imbecility, or even insanity. Aside from these 
considerations, prenatal syphilis and postnatal syphilis are identical. 

To recur for a moment to the mode of infection. It has already 
been stated that the mother must always be syphilitic in order to 
have the disease transmitted to the offspring. At times it is difficult 
to explain the infection, the father having had no active local mani- 
festations, and perhaps no general ones, or only a Wassermann reac- 
tion. It is conceivable, in view of Warthin's work, that spirochetes 
may have been inactive but present in the testes and that the mother 
may have been infected by the seminal fluid containing micro-organ- 
isms. This does not imply that the spermatozoa conveyed the patho- 
genic agent. 

Prognosis and Treatment. In general the outlook for a syph- 
ilitic baby is not good. In patients born with cutaneous and marked 
general evidences the prognosis is bad. The treatment consists of 
arsphenainin injections of one to ten milligrams a week, into the 
jugular vein, and daily rubbings with a gram of ammoniated mer- 
cury salve (U.S.P.). In patients with cutaneous and slight systemic 
evidences the prognosis is better, and the treatment as above. In 
patients with cutaneous lesions alone, and later systemic manifesta- 
tions the outlook is still better, and the treatment again the same. 
When apparently healthy infants develop symptoms within a year, 
the prognosis is good ; the treatment as outlined, save that gray oint- 
ment may be used instead of ammoniated mercury, the dose being 
the same. When the manifestations arise between the second and 
seventh years, the prognosis becomes that of acquired syphilis. The 
treatment consists of all the methods outlined in the chapter on 
treatment of acquired syphilis, but the dose of the arsenical solution 
should not exceed 0.1 a week, the site of the vein employed depending 
upon the child's build and tractability, and the choice of mercurial 
injections or inunctions depending upon these factors too. The dose 
of mercury injected should not exceed a half grain, nor the quantity 
rubbed in one and a half grams. In late congenital syphilis the 
prognosis and treatment absolutely parallel conditions in late acquired 
syphilis. 



INDEX 



Abdominal viscera, syphilis of, 428 
Acanthosis nigricans, 196, 328 

difl'erentiated from Psorospermosis, 
187 
Acarodermatitis urticarioides, 232 
Acarus scabiei, 226 
Accident primitif, 397, and see Syphilis 

acquired, primary stage 
Achorion, 254 

Achromia, 214, and see Vitiligo 
Acids in relation to skin diseases, 9 
Acid salts in relation to skin diseases, 9 
Acne, 364 
course, 366 
definition, 364 
differential diagnosis, 366 
differentiated from Folliculitis sup- 
purativa barbae staphylogenes, 
267 
etiology, 366 
prognosis, 368 
symptoms, 364 
synonyms, 364 
treatment, 367 
varieties, 366 
Acne decalvante, 359, and see Follicu- 
litis decalvans 
keloid, 272, 368 
necrotica, 292 

differentiated from Acne, 366 
rosacea, 369, and see Rosacea 
syphilitica, 409 

telangieetatica, 291, and see Papu- 
lonecrotic tuberculides 
varioliformis, 292, and see Acne ne- 
crotica 
vulgaris, 272, 364, and see Acne 
Acne, 364, and see Acne 
Acnitis, 290, 291, and see Papulone- 
crotic tuberculides 
Acquired diseases of the skin, 9 
Acrodermatitis atrophicans chronica, 
208 
perstans, 133 
Acromegaly, 202 
Actinomycosis, 260 
Acuminate papule in syphilis, 408 
Addison's disease, 212 

keloid, 205 
Adenoma sebaceum, 353 
Adrenals, disturbances of in relation to 

skin diseases, 15 
Age, in relation to diseases of skin, 11 
Ainhum, 207 

455 



Albinism, 215 

Aleppo boil, 233, and see Oriental boil 
Alkalies, in relation to skin diseases, 9 
Alkaline salts, in relation to skin dis- 
eases, 9 
Alopecia, 161 

differentiated from Microsporosis, 
243 
Alopeca areata, 361 

course, 361 

definition, 361 

differential diagnosis, 362 

differentiated from Folliculitis decal- 
vans, 359 
from Lupus erythematosus, 295 

etiology, 362 

prognosis, 362 

symptoms, 361 

synonyms, 361 

treatment, 362 

varieties, 362 
Alopecia areolaris, 361, and see Alope- 
cia areata 

cicatrisata, 359, and see Folliculitis 
decalvans 

circumscripta, 359, and see Follicu- 
litis decalvans 

generalisata, 362 
Alphos, 145, and see Psoriasis 
Anal dermatitis (Eczema), 111 

diseases, 387 
Anaphylactoid reactions, 432 
Anaphylatoxins, in relation to skin dis- 
eases, 14 
Anaphylaxis, in urticaria, 43, 44, 45 
Angina, Vincent's, 387 
Angio-elephantiasis, 349 
Angio-keratoma, 87 

of Mibelli, 300 
Angio-lipoma, 349 
Angioma, 347, and see Vascular nevi 

cavernosum, 349 

flat, 348 

infective, 88, and see Angioma ser- 
piginosum 

raised, 348 
Angioma serpiginosum, 88 

course, 88 

definition, 88 

differential diagnosis, 89 

etiology, 89 

pathogenesis, 89 

prognosis, 89 

symptoms, 88 



456 



INDEX 



Angioma serpiginosum (continued) 

synonyms, SS 

treatment, S9 

varieties, 89 
Angioneuroses, drugs producing, 56 
Angioneurotic edema, 41, 48 

course, 48 

definition, 4S 

differential diagnosis, 48 

etiology, 40 

pathogenesis, 49 

symptoms, 4b 

synonyms, 48 

treatment, 49 
Anhidrosis, 372 
Animal parasites, 223 

in relation to skin diseases, 10, 14 

lesions caused by, 224 
Annular syphilide, 408 
Anthrax, 271, 274, and see Carbuncle 

course, 274 

definition. 274 

differential diagnosis, 274 

etiology, 275 

prognosis, 275 

symptoms, 274 

synonyms, 274 

treatment, 275 

varieties, 274 
Antipyrin, eruption following use of, 64 
Anus, diseases of, 383 
Area Celsi, 361, and see Alopecia 

areata 
Argyria, 63 

Arsenic, eruption following use of, 61 
Arsphenamin, eruption following use 
of, 61 

in treatment of syphilis, 430, 435 

technic of administration, 430 

toxicity of, 431 
Aspirin, eruption following use of, 65 
Atheromas, 368 
Atrophia cutis diffusa idiopathica, 208 

maculosa et striata idiopathica, 208 

senilis, 208 
Atrophies of connective tissue, 204 

of skin, 204 
Atrophoderma neurotica, 209 

senile, 208 
Atrophy, diffuse idiopathic, 208 

senile, 208 
Aurelia aurea, 232 
Aussatz, 301, and see Lepra 
Autochthonous skin diseases, 8 

Bacilli, as cause of skin diseases, 9 
Bacteria, as cause of skin diseases, 9, 14 
Bacterial infections, miscellaneous, 274 
Bacterial toxins, as cause of skin dis- 
eases, 14 
Bacteriological study of skin diseases, 
27 



Balanitis, erosive, 97 

errosiva et gangrenosa, 277 
Baldness, 359, 363 
etiology, 358 
seborrhoeal, 161 
varieties, 358 
Barbados leg, 199, and see Elephanti- 
asis 
Barber's itch, 247, and see Trichophy- 
tosis barbae 
Barlow's disease, 82 
Bartfinne, 266, and see Folliculitis 
suppurativa barbae staphy- 
logenes 
Bartflechte, 266, and see Folliculitis 
suppurativa barbae staphy- 
logenes 
Bartonia bacilliformis, 236 
Baziirs disease differentiated from 

Erythema nodosum, 38 
Bedsores, 95, and see Decubitus 
Belladonna, eruption following use of, 

59 
Biskra boil, 233, and see Oriental boil 

button, 233, and see Oriental boil 
Bismuth, eruption following use of, 62 
Blaschenflechte, 98, and see Herpes 
Blasenausschlag, 134, and see Pemphi- 
gus 
Blastomycosis, 255 
course, 256 
definition, 255 
differential diagnosis, 257 
differentiated from Lupus vulgaris, 
285 
from Scrofuloderma, 288 
from Tuberculosis verrucosa cutis, 
286 
etiology, 258 
pathogenesis, 258 
prognosis, 258 
symptoms, 256 
synonyms, 255 
treatment, 258 
varieties, 256 
Blattern, 72, and see Variola 
Blebs, 20 
Bleeders, 81 

Blood, disorders of in relation to skin 
diseases, 16 
examination of in skin diseases, 28 
Blutbeule, 268, and see Furunculosis 
Body lice, 229, and see Pediculosis 

corporis 
Bockhart, impetigo of, 268, and see 

Impetigo of Bockhart 
Boeck's sarcoid, 298 
Boil, 268, and see Furunculosis 
Aleppo, 233, and see Oriental boil 
Biskra, 233, and see Oriental boil 
Delhi, 233, and see Oriental boil 
Bone, syphilis of, treatment, 440 



INDEX 



457 



Bothriomycosis, 277, and see Granu- 
loma pyogenicum 

Bouton de Biskra, 233, and see Oriental 
boil 
d'Orient, 233, and see Oriental boil 

Bower's precancerous dermatosis, 188 

Brandschwur, 271, and see Carbuncle 

Brill's disease, 78 

Bromide acne differentiated from Acne, 
3G6 
eruption differentiated from syphilis, 
410 

Bromides, eruption following use of, 64 

Bromidrosis, 372 

Bromoderma tuberosa, 311 

Bronzing, 212 

Buccal mucosa, diseases of, 383, 384, 
385, 386 

Bullae, 20 

due to drugs, 14 
drugs producing, 56 

Bullous dermatoses, 134 

Burns, 132 



Cachexia, in relation to skin diseases, 
16 

strumipriva, 202 

thyroid, 202 
Calcareous deposits, 219 
Calcification, 219 
Callositas, 194, and see Callus 
Callosities differentiated from Kera- 
toma palmaris et plantaris, 
195 
Callus, 194 

course, 194 

definition, 194 

diagnosis, 194 

etiology, 194 

pathogenesis, 194 

symptoms, 194 

synonyms, 194 

treatment, 194 
Cancer, 320, and see Epithelioma 

en cuirasse, 327 

of penis, 330 
Cancroid, 320, 325', and see Epitheli- 
oma, and Epithelioma, basal 
celled 
Canities, 361 
Canker sore, 386 
Carbuncle, 271 

course, 272 

definition, 271 

differential diagnosis, 272 

etiology, 272 

prognosis, 272 

symptoms, 271 

synonyms, 271 

treatment, 272 
Carbunculus, 271, and see Carbuncle 



Carcinoma, 320, and see Epithelioma 

papulo-tubercular, 327 

Roentgen, 335 

scirrhous, 327 
Carcinome, 320, and see Epithelioma 
Cardiovascular syphilis, 426 

treatment. 437 
Carrel-Dakin solution, dermatitis from, 

113 
Carrion's disease, 235, and see Verruga 

Peruviana 
Cerebrospinal fluid, changes in, in 
syphilis of nervous system, 
425 

meningitis, 79 
Chancre, 397, and see Syphilis, ac- 
quired, primary sore 

de Sahara, 233, and see Oriental boil 

extragenital, 398, 399 

hard, 397 

Hunterian, 397, 398 

mixte, 399 

prognosis, 401 

redux, 399 
Chapping, 114 

Charbon, 274, and see Anthrax 
Cheilitis glandularis, 386 
Cheiropompholyx, 103 
Cheloid, 198, and see Keloid 
Chemical agents, causing skin diseases, 
9 

elements, as cause of skin diseases, 9 
Chiekenpox, 75, and see Varicella 
Chilblain lupus, 297 
Chilblains differentiated from Lupus 

erythematosus, 295 
Chloasma, 211 

Chloral, eruptions following use of, 64 
Chloromata, 342 
Chromaffin system, disturbances of as 

cause of skin diseases, 15 
Chromidrosis, 372 
Chromophytosis, 240, and see Pityriasis 

versicolor 
Chrysarobin, leucoderma from, 215 
Cicatrice, 197, and see Scar 
Cicatrices, 23, 197, and see Scar 
Clavus, 194 

Clou, 268, and see Furunculosis 
Cocci, as cause of skin diseases, 9 
Coccidoidal infections, 260 
Cochin leg, 199, and see Elephantiasis 
Cold, as cause of skin dseases, 9 
Cold abscess of skin, 287, and see Scro- 
fuloderma 

sore, 98, and see Herpes 
Colloid degeneration, 219 

milium, 219 
Color of skin lesions, 24 
Comedones, 364 
Condyloma acuminatum, 187 

course, 188 

definition, 187 



458 



INDEX 



Condyloma acuminatum {continued) 
diagnosis, 1S8 
etiology, 188 
pathogenesis, 188 
prognosis, 188 
synonyms, 187 
treatment, 188 
Condyloma, flat, 407 
Condylomata differentiated from syphi- 
lis, 407 
Condylomatosis, 139, and see Pem- 
phigus vegetans 
Congenital diseases of the skin, 8 
syphilis, 415, 444, and see Syphilis, 
congenital 
Conjunctiva, diseases of, 383 
Cootie, 229 

Copaiba, eruption following use of, 60 
rash differentiated from syphilis, 406 
Copra itch, 232 
Corn, 194 

Cornu cutaneum, 195 
Corona Veneris, 407, 413 
Couperose, 369, and see Rosacea 
Crabs, 230, and see Pediculosis pubis 
Creeping eruption, 231, and see Larva 

migrans 
Cretes de Coq, 187, and see Condyloma 

acuminatum 
Cretinoid edema, 202 
Crusts, 21 

Cutaneous epithelioma, 321 
horn, 195 
lesions, 18 

bacteriological study of, 28 

blood examination in, 28 

color of, 23 

diagnostic procedures in, 26 

grouping of, 25 

laboratory methods of examination, 

27 
luetin test in, 29 
primary, 18 
secondary, 18, 21 
shape of, 24, 25 
special tests in, 29 
reactions, 13 

characterized by scaling or licheni- 
fication, 145 
by serous exudation, 98 
due to vascular disturbances, 33 
vessels, diseases of, 83 
Cutis laxa, 202, 219 
marmorata, 40 

differentiated from Purpura annu- 
laris telangiectoides, 87 
verticis gyrata, 202 
Cyanosis, drugs producing, 56 
Cysticerci of taenia solium, 232 

Darier's disease, 186, and see Psorosper- 
mosis 



Darier's sarcoid, 298 

differentiated from Erythema in- 
duratum, 300 
Darier-Roussy's sarcoid, 298 
Dartre, 98, and see Herpes 
Decubitus, 95 

treatment, 96 
Delhi boil, 233, and see Oriental boil 
Delousing, 230 
Demodex folliculorum, 232 
Depigmentation, 210, 214 

varieties of, 214 
Dermamyiasis linearis migrans aes- 

trosa, 231 
Dermatalgia, 382 

Dermatite exfoliante a'igue benigne, 
171 
polymorphe et douloureuse, 141, and 
see Dermatitis herpetiformis 
Dermatitis, 104, and see Dermatitis 
(Eczema) 
differentiated from Epidermophytia 
inguinalis, 252 
Dermatitis, acute infectious bullous, 
134, and see Pemphigus acutus 
blastomycetic, 255, and see Blastomy- 
cosis 
bullous, following vaccination, 59 
calorica, 132 
congelationis, 132 
cracquele, 106 

crustosa, see Dermatitis madidans 
Dermatitis (Eczema), 103 
course, 105 
definition, 104 
differential diagnosis, 116 
erythematous, 116 
etiology, 123 
papular, 117 
pathogenesis, 123 
prognosis, 132 
squamous, 117 
symptoms, 104 
synonyms, 104 
treatment, 127 
varieties, 105 
vesiculobullous, 117 
vesiculopustular, 117 
Dermatitis erysipelatosa, 170 
erythematosa, 106 

exfoliativa, 167, 168, and see Erythro- 
dermas, and Pityriasis rubra 
(of Hebra) 
differentiated from Pityriasis ru- 
bra (of Hebra), 169 
epidemica, 170 
neonatorum, 170 
factitia, 133 
fissa, 106 
Dermatitis gangrenosa infantum, 94 
course, 95 
definition, 94 



INDEX 



459 



Dermatitis gangrenosa infantum {con- 
tinued) 
differential diagnosis, 95 

etiology, 95 

pathogenesis, 95 

prognosis, 95 

symptoms, 94 

synonyms, 94 

treatment, 95 
Dermatitis herpetiformis, 141 

course, 142 

definition, 141 

differential diagnosis, 142 

differentiated from Pemphigus 
acutus, 135 

etiology, 143 

pathogenesis, 143 

prognosis, 143 

symptoms, 141 

synonyms, 141 

treatment, 143 

varieties, 142 
Dermatitis hiemalis, differentiated from 
Scabies, 226 

impetiginoides, 106 

infantile, 115 

infectious eczematoid, 272 

lichenoides, 107 

madidans, 107 

nummularis, 107 

occupational, 113 

papillaris capillitii, 272, 368 

papular, differentiated from Lichen 
scrofulosorum, 290 
differentiated from Prurigo, 53 

papulosa, see Dermatitis lichenoides 

parapsoriatic, differentiated from 
Granuloma fungoides, 307 

psoriasiformis nodularis, 156 

pustulosa, 106 

repens, 133 

rhagadiformis, 106 

rubra, 107 

sclerosa, 107 

sclerotisans nuchae, 368 

seborrhoeal, 159, 161 

senile, 116 

simple, 103 

squamosa, 107 

squamous, differentiated from Granu- 
loma fungoides, 307 

traumatica, 132 

uncinarial, 231 

venenata, 113 

verrucosa, 107 

vesicular, differentiated from Lichen 
planus, 177 
from Pediculosis corporis, 229 
from Scabies, 226 

vesiculosa, 108 
Dermatology, see Cutaneous lesions 

relation to internal medicine, 12 
Derm atoly sis, 202, 219 



Dermatomycoses, 242 

Dermatosclerosis, 204, and see Sclero- 
derma 

Dermatoses, see Cutaneous lesions 
bullous, 134 
precancerous, 188, 331 
psoriasiform, 145 

Dermographism, 42 

Dermoid cysts, 334 

Dhobie itch, 253 

Diabetic gangrene, 92 

Diagnostic procedures, 26 

Dichloramin-T, dermatitis from use of, 
113 

Digitalis, eruption following use of, 60 

Diphtheria of skin, 275 

Discoid syphilide, 407 

Dissection tubercle, 286, and see Tuber- 
culosis verrucosa cutis 
wounds, 273 

Dohle's bodies, 71 

Dranunculus, 232 

Drug dermatoses, differentiated from 
Blastomycosis, 257 
eruptions, 55, 56 

Drugs, skin diseases due to, 13, 14 

Duhring's disease, 140, 141, and see 
Dermatitis herpetiformis 

Duke's disease, 69 

Dyskeratoses, 184, 185 

Dystrophic papillaire et pigmentaire, 
196 

Dystrophies of the skin, 184, 185, 197 



Eccem, 104, and see Dermatitis (Ec- 
zema) 
Echinococcus, 231 

cysts, 231 
Ecthyma, 263 
course, 263 
definition, 263 
differential diagnosis, 263 
differentiated from Syphilis, 411 
etiology, 264 
prognosis, 264 
symptoms, 203 
treatment, 264 
varieties, 263 
Ecthyma cachecticum, 94, and see 
Dermatitis gangrenosa in- 
fantum 
gangrenosum, 94, and see Dermatitis 

gangrenosa infantum 
terebrans infantum, 94, and see Der- 
matitis gangrenosa infantum 
Ecthymatous syphilis, 411 
Eczema, 103, and see Dermatitis (Ec- 
zema) 
flexurarum, 112 
follicular, 300 

marginatum, 252, and see Epidermo- 
phytia inguinalis 



460 



INDEX 



Eczema marginatum (continued) 

differentiated from Dermatitis 
(Eczema), 121 
papillosum, 181, and see Lichen 

chronicus (simplex) 
professional, 113 
Eczema, 104, and see Dermatitis (Ec- 
zema) 
Edema, acute circumscribed, 48, and 
see Angioneurotic edema 
acute essential, 48, and see Angio- 
neurotic edema 
angioneurotic, 41, 48, and see Angio- 
neurotic edema 
cretinoid, 202 
neonatorum, 201 
Quincke's, 48, and see Angioneurotic 

edema 
wandering. 48, and see Angioneurotic 
edema 
Eiterbeule, 268, and see Eurunculosis 
Eiterflechte, 261, and see Impetigo con- 
tagiosa 
Eitergeschwiir, 268, and see Furuncu- 

losis 
Ekzem, 104, and see Dermatitis (Ec- 
zema ) 
Elastic skin, 202 

Elephant leg, 199, and see Ele- 
phantiasis 
Elephantiasis, 199, 232 
course, 200 
definition, 199 
differential diagnosis, 200 
etiology, 200 
pathogenesis, 200 
prognosis, 201 
symptoms, 199 
synonyms, 199 
treatment, 201 
varieties, 200 
Elephantiasis Arabum, 199, and see 
Elephantiasis 
Graecorum, 301, and see Lepra 
telangiectatic nevoid, 200 
telangiectoides, 200 
tuberculosis cutis, 286 
Enanthem, 65 
Encephalitis lethargica, 80 
Endemische Beulenkrankheit, 233, and 

see Oriental boil 
Endocarditis, bacterial, 79 
Endothelioma, 320, 328 
Entzunaliche fungose geschwulstform, 
305, and see Granuloma fun- 
go ides 
Environment in its relation to diseases 

of the skin, 10 
Ephelides, 212 
Epidemic roseola, 68, and see German 

measles 
Epidermal dystrophies, 184, 185 



Epidermolysis bullosa acquisita, 144 

bullosa hereditaria, 144 
Epidermophytia inguinalis, 121, 252, 
and see Eczema marginatum 

course, 252 

definition, 252 

differential diagnosis, 252 

etiology, 253 

pathogenesis, 253 

prognosis, 253 

symptoms, 252 

synonyms, 252 

treatment, 253 

varieties, 252 
Epithelial proliferation, due to drugs. 

14 
Epitheliom, 320, and see Epithelioma 
Epithelioma, 319, 320 

classification. 320, 321 

definition, 320 

diagnosis, 344 

differentiated from Chancre, 401 
from Lupus erythematosus, 296 

synonyms, 320 
Epithelioma adenoides cysticum, 352 
Epithelioma, basal celled, 325 

course, 326 

definition, 325 

differential diagnosis. 326 

etiology, 327 

pathogenesis, 327 

prognosis, 327 

symptoms, 325 

synonyms, 325 

treatment, 327 

varieties, 326 
Epithelioma contagiosum, 185, and see 
Molluscum contagiosum 

cutaneous, 321 
Epithelioma, cutaneous prickle celled, 
321 

course, 322 

definition, 321 

diagnosis, 322 

etiology, 323 

pathology, 323 

prognosis, 325 

symptoms, 322 

synonyms, 321 

treatment, 324 

varieties, 322 
Epithelioma, eczematous, of nipple, 
328 

lobular, 321, and see Epithelioma, cu- 
taneous prickle celled 

molluscum, 185, and see Molluscum 
contagiosum 

muco-cutaneous, 321, 329 

mucous, 321, 329 

of lip, 329, 387 

of nipple, eczematous, 328 

of tongue, 329, 387 



INDEX 



461 



Epithelioma of tongue (continued) 

differentiated from Lingual tuber- 
culosis, 289 
pigmentary, 321, 328 
primary, 321 
sclerodermatous, 326 
secondary, 321, 327 
spinocellulare, 321, and see Epi- 
thelioma, cutaneous prickle 
celled 
squamous celled, 321, and see Epi- 
thelioma, cutaneous prickle 
celled 
Epitheliome, 320, and see Epithelioma 
lobule, 321, and see Epithelioma, 

cutaneous prickle celled 
epinocellulaire, 321, and see Epi- 
thelioma, cutaneous prickle 
celled 
Equinia, 275 

Erbgrind, 253, and see Favus 
Ergotism, 97 

Eruption, feigned, 133, and see Derma- 
titis factitia 
following use of drugs, 55 
ringed, 300 

syphilitic, 402, 405, and see Syphilo- 
derm 
Erysipel, 264, and see Erysipelas 
Erysipelas, 264 
course, 264 
definition, 264 
differential diagnosis, 265 
differentiated from Dermatitis (Ec- 
zema), 118 
etiology, 265 
prognosis, 266 
symptoms, 264 
synonyms, 264 
treatment, 265 
varieties, 264 
Erysipelas perstans faciei (Kaposi), 

297 
Erysipele, 264, and see Erysipelas 
Erysipeloid, 260 
Erythema, 33 

drugs causing, 55 
due to drugs, 13 
physiological, 39 
toxic, 39 

differentiated from Syphilis, 
405 
Erythema ab igne, 40 
annulare, 36 
bullosum, 36 

differentiated from Pemphigus 
acutus, 135 
"bullosum vegetans, 139, and see Pem- 
phigus vegetans 
centrifugum, 292, and see Lupus 

erythematosus 
circinatum, 36 



Erythema (contvmed) 

contusiforme, 37, and see Erythema 
nodosum 

elevatum diutinum, 40 

figuratum, 36 

fugax, 40 

gangrenosum, 40 

hyperemicum, 40 

infantum, 40 

indurativum, 299, and see Erythema 
induratum 

indurativum, of Bazin, 38 
Erythema induratum, 299 

course, 299 

definition, 299 

differential diagnosis, 300 

differentiated from Lupus vulgaris, 
285 
from Sarcoid, 299 

etiology, 300 

prognosis, 300 

symptoms, 299 

synonyms, 299 

treatment, 300 
Erythema intertrigo, 40 

iris, 36 

laeve, 40 

migrans, 386 

multiforme, differentiated from Syph- 
ilis, 405 
Erythema multiforme exudativum, of 
Hebra, 35 

course, 36 

definition, 35 

differential diagnosis, 36 

etiology, 37 

pathogenesis, 37 

prognosis, 37 

symptoms, 35 

treatment, 37 

varieties, 36 
Erythema nodosum, 37 

course, 38 

definition, 37 

differential diagnosis, 38 

differentiated from Sarcoid, 299 

etiology, 38 

pathogenesis, 38 

prognosis, 39 

symptoms, 38 

synonyms, 37 

treatment, 39 
Erythema papulatum, 36 

papulosum, 36 

perstans, 40 

recidivans, of Fereol and Besnier, 
171 
Erythema scarlatiniforme, 34 

definition, 34 

differential diagnosis, 35 

etiology, 34 

pathogenesis, 34 



462 



ESTDEX 



Erythema scarlatiniforme {contd.) 
prognosis, 35 
symptoms, 34 
synonyms, 34 
treatment, 35 
Erythema scarlatiniforme desquativum, 
171 
scarlatinoid, 171 
simplex, 40 
solare, 40 

symptomaticum, 40 
toxicum, 36 
tuberculosum, 36 
urticatum. 36 
vesiculosum, 36 
Erytheme indurg des scrofuleux, 299, 
and see Erythema induratum 
infectieux, 34 

noueux, 37, and see Erythema no- 
dosum 
Erythrasma, 241 

differentiated from Dermatitis (Ec- 
zema), 122 
from Epidermophytia inguinalis, 
252 
Erythroderma, 167 

differentiated from Psoriasis, 148 
drugs producing, 56 
primary, 167 
secondary, 167 

differentiated from Pityriasis ru- 
bra of Hebra, 169 
Erythroderma congenitale ichthyosi- 
forme, 353 
desquamative neonatorum, 170 
ichthyosiformis congenita, 171 
resistant maculopapular scaling, 156, 
and see Parapsoriasis 
Erythrodermie congenitale ichthyosi- 
forme, 192 
pityriasique en plaques disseminees, 
156 
Erythromelalgia, differentiated from 

Raynaud's disease, 94 
Etiology of skin diseases, 3 
Exanthemata, 55, 65 
Excoriations, 22 

Exposure as cause of skin diseases, 9 
Extragenital chancres, 398, 399 

Farcin, 275 
Farcy, 275 

Fasernepithelkrebs, 321, and see Epi- 
thelioma, cutaneous prickle 
celled 
Favus, 253 
course, 254 
definition, 253 
differential diagnosis, 254 
differentiated from Alopecia areata, 
362 
from Dermatitis (Eczema), 119 



Favus (continued) 

diiferentiated from Folliculitis de- 
calvans, 359 
from Gumma. 419 
from Lupus erythematosus. 295 

etiology, 255 

pathogenesis. 255 

prognosis, 255 

symptoms. 253 

synonyms. 253 

treatment, 255 

varieties, 254 
Feces, examination of. in skin diseases. 29 
Feigned eruptions, 133 
Fever blister, 98, and see Herpes 
Fevers, prolonged, in relation to skin 

diseases, 16 
Fibroma, 337 

course, 337 

definition, 337 

diagnosis, 344 

differential diagnosis, 339 

etiology, 339 

prognosis, 339 

symptoms, 337 

synonyms, 337 

treatment, 339 

varieties, 337 
Fibroma durum, 337, 339, and see Fi- 
broma 

molle, 338 

molluscum, 337, and see Fibroma 

pendulum, 338 
Fibromata, multiple, 337, and see Reck- 
linghausen's disease 
Fibromatosis tuberculosa cutis. 28 ! 
Fig- wart, 187, and see Condyloma acu- 
minatum 
Filaria sanguinis hominis, 232 

medinensis, 232 
Filatow"s spots, 66, 67 
Fishskin disease, 191, and see Ichthy- 
osis 
Fleckenmaal, 346, and see Xevus pig- 
mentosa 
Flindt's spots, 66, 67 
Follicles, hair, diseases of, 357 
Folliclis, 290, 291, and see Papulone- 
crotic tuberculides 
Follicular tonsillitis, 79 
Folliculitis decalvans, 359 

course, 359 

definition, 359 

differential diagnosis, 359 

differentiated from Alopecia areata, 
362 

etiology, 360 

prognosis, 360 

symptoms, 359 

svnonvms, 359 

treatment, 360 

varieties, 359 



INDEX 



463 



Folliculitis, staphylococcus, differenti- 
ated from Acne, 366 
differentiated from Folliculitis decal- 
vans, 360 
Folliculitis suppurativa barbae sta- 
phylogenes, 266 
course, 267 
definition, 266 
differential diagnosis, 267 
etiology, 267 
prognosis, 268 
symptoms, 266 
synonyms, 266 
treatment, 267 
varieties, 267 
Folliculitis suppurativa trichophytica 

barbae, 248 
Fordyce's disease, 386 
Fournier's delayed congenital syphilis, 

447 
Fourth disease, 69 
Fragilitas crinium, 361 
Frambesia, 234 
definition, 234 
differential diagnosis, 235 
differentiated from Verruga Peruvi- 
ana, 236 
etiology, 235 
pathogenesis, 235 
prognosis, 235 
symptoms, 234 
synonyms, 234 
treatment, 235 
Freckles, 212 

differentiated from Pityriasis versi- 
color, 240 
Freezing, 132, and see Dermatitis con- 

gelationis 
French measles, 68, and see German 

measles 
Frostbite, differentiated from Ray- 
naud's disease, 93 
Fungi, as cause of skin diseases, 10, 14 

infections caused by, 239 
Fungoid neoplasm, 305, and see Granu- 
loma fungoides 
Furuncle, differentiated from Anthrax, 
274 
from Chancre, 401 
from Molluscum contagiosum, 186 
Furunculosis, 268 
course, 269 
definition, 268 
differential diagnosis, 269 
etiology, 269 
prognosis, 271 
symptoms, 269 
synonyms, 268 
treatment, 269 
varieties, 269 
Furunculus, 268, and see Furunculo- 
sis 



Gafsa button, 233, and see Oriental boil 
Gale, la, 225, and see Scabies 
Gangosa, 276 
Gangrene, 83 

causes, 90, 91 

diabetic, 92 

hysterical, 133 

multiple disseminated, of skin, 94, 
and see Dermatitis gangrenosa 
infantum 

neurotic, 133 

nosocomial, 97 

spontaneous, 133 

symmetrical, of the extremities, 93, 
and see Raynaud's disease 
Gangrenous stomatitis, 96, and see 

Noma 
Gastric contents, examination of in skin 

diseases, 29 
Gastro-intestinal indigestion, as cause 

of skin diseases, 15 
Gayle, 272 

Gefassmal, 347, and see Vascular nevi 
Genital mucosa, diseases of, 383 

dermatitis (Eczema), 112 
Geographical tongue, 386 
German measles, 68 

complications, 68 

course, 68 

definition, 68 

diagnosis, 68 

etiology, 68 

pathogenesis, 68 

prognosis, 68 

sequelae, 68 

symptoms, 68 

synonyms, 68 

varieties, 68 
Giant urticaria, 42, 48, and see Angio- 
neurotic edema 
Glandular fever, 80 
Glans penis, diseases of, 388 
Glossina palpalis, 235 
Glossitis areata, 386 

Moeller's, 386 
Glossy skin, 209 
Gomme scrofulo-tuberculeuse, 287, and 

see Scrofuloderma 
Graefe's essential shrinking, 383 
Granuloma annulare, 300 
Granuloma fungoides, 305, and see My- 
cosis 

compared with Leucemia cutis, 304 

course, 306 

definition, 305 

differential diagnosis, 306 

differentiated from Leucemia cutis, 
310 
from Sarcoma, 342 

etiology, 308 

pathogenesis, 308 

prognosis, 308 



464 



INDEX 



Granuloma fungoides (continued) 
symptoms, 305 
synonyms, 305 
treatment, 308 
varieties, 306 
Granuloma necroticum, 292, and see 

Acne necrotica 
Granuloma pyogenicum, 277 

definition, 277 

differential diagnosis, 278 

etiology, 278 

prognosis, 278 

symptoms, 278 

synonyms, 277 

treatment, 278 
Granuloma telangiectaticum, 277, and 
see Granuloma pyogenicum 

ulcerating, of the pudenda, 235 
Granulomata, 304 

drugs producing, 56 

due to drugs, 14 

massive, 280, 282 

miliary, 282 

non-infectious, 304 
Granulosis rubra nasi, 353 
Graves' disease, hyperpigmentation in, 

212 
Grooved tongue, 386 
Ground itch, 231 
Guinea worm, 232 
Gumma, 416, 422 

differentiated from Chancre, 401 

gummatous, 418 

massive, 418 

nodular, 416 

serpiginous, 416 

squamous, 417 

subcutaneous, 418 
Gunpowder, pigmentation from, 213 
Giirtelausschlag, 100, and see Zoster 
Giirtelrose, 100, and see Zoster 

Habit, as cause of skin diseases, 10 

Hair, diseases of, 357, 358 

Hairy black tongue, 260, 386 
nevi, 346 

Hangnails, 376, 377 

Hautfinne, 364, and see Acne 

Hautsclerem, 204, and see Scleroderma 

Head lousiness, 227, and see Pediculosis 
capitis 

Heat, as cause of skin diseases, 9 

Hefenmycosis, 255, and see Blastomy- 
cosis 

Hemachromatosis, 213 

Hemangio-lymphangioma, 349 

Hematidrosis, 372 

Hemiatrophia facialis, 206 

Hemoglobin, hyperpigmentation derived 
from, 211 

Hemophilia, 81 

Henoch's purpura, 81 



Hereditary diseases of the skin, 8, 9 

Herpes, 98 

course, 99 

definition, 98 

differential diagnosis, 99 

differentiated from Dermatitis (Ec- 
zema), 118 

drugs producing, 56 

etiology, 99 

pathogenesis, 99 

prognosis, 100 

symptoms, 98 

synonyms, 98 

treatment, 100 

varieties, 99 
Herpes aestivalis, 143 

gestationis, 141, and see Dermatitis 
herpetiformis 

iris, 36 

simplex, 98, and see Herpes 

tonsurans, 245 

tonsurans maculosus, 157, and sec 
Pityriasis rosea 

vegetans, 139, and see Pemphigus 
vegetans 

zoster, 100, and see Zoster 
Herxheimer reaction, 433 
Hide-bound, 204, and see Scleroderma 
Hirsuties, 360 
Horn, cutaneous, 195, 334 
Hunterian chancre, 397, 398 
Hutchinson's teeth, 450 

triad, 450 
Hyaloma, 219 
Hydroa vacciniforme, 143 
Hydrocystoma, 373 
Hydrosis, 371 
Hyperhidrosis, 371 
Hyperkeratosis, 184, 190 

differentiated from Keratoma pal- 
maris et plantaris, 195 

drugs producing, 56 
Hyperpigmentations, 210 

causes, 211 

treatment, 213 
Hyperplastic skin, 202 
Hypernephromata, 342 
Hypersarcosis, 199, and see Elephan- 
tiasis 
Hypertrichosis, 360 

Hypertrophies of connective tissue, 197 
Hypohidrosis, 372 
Hysteria, 380 
Hysterical mutilations, 97 

Ichthyosis, 191, 353 
course, 191 
definition, 191 
differential diagnosis, 192 
etiology, 192 
pathogenesis, 192 
prognosis, 193 



INDEX 



465 



Ichthyosis ( continued ) 
symptoms, 191 
synonyms, 191 
treatment, 192 
varieties, 192 
Ichthyosis congenita, 192 
follicularis, 192 
hystrix, 191 

of palms and soles, 195, and see 
Keratoma palmaris et plan- 
taris 
simplex, 191 
Ignis sacer, 100, and see Zoster 
Impetigo, 261, and see Impetigo con- 
tagiosa 
differentiated from Ecthyma, 263 
from Favus, 255 
from Gumma, 419 
Impetigo cachectica, 94, and see Der- 
matitis gangrenosa infan- 
tum 
Impetigo contagiosa, 261 
course, 261 
definition, 261 
differential diagnosis, 262 
differentiated from Dermatitis (Ec- 
zema), 120 
from Syphilis, 411 
etiology, 262 
prognosis, 263 
symptoms, 261 
synonyms, 261 
treatment, 262 
varieties, 262 
Impetigo of Bockhart, 268 

differentiated from Dermatitis (Ec- 
zema), 120 
from Folliculitis decalvans, 360 
Induration, 397, and see Syphilis, ac- 
quired, primary stage 
Infantile dermatitis, 115 
Infantile prurigo, 50 
course, 51 
definition, 50 
differential diagnosis, 51 
etiology, 51 
prognosis, 51 
symptoms, 50 
synonyms, 50 
treatment, 51 
Infantile scurvy, 82 
Infections of skin, 221 
bacterial, 274 
caused by fungi, 239 
by protozoa, 233 
Inflammatory fungoid neoplasm, 305, 

and see Granuloma fungoides 
Ingrown nail, 376 

Initial affekt, 397, and see Syphilis, 
acquired, primary stage 
lesion, 397, and see Syphilis, ac- 
quired, primary stage 



Initial sore, 397, and see Syphilis, ac- 
quired, primary stage 
Insects as cause of skin diseases, 10 
Internal secretions, disturbances of as 

cause of skin diseases, 15 
Intertrigo, 40, 103 
Iodide acne differentiated from Acne, 

366 
Iodides, eruption following use of, 63 
eruption differentiated from Syphilis, 

410 
in treatment of syphilis, 430, 435 
Iododerma tuberosa, 311 
Iodoform, eruption following use of, 

64 
Itch, 225, and see Scabies 

barber's, 247, and see Trichophytosis 

barbae 
Copra, 232 
Dhobie, 253 
ground, 231 

seven years', 225, and see Scabies 
Itching, 381 
Ivy poisoning, 113 
Ixodes, 232 



Jacob's ulcer, 325, and see Epithelioma, 

basal celled 
Jelly fish, 232 

as cause of skin disease, 10 
Joints, syphilis of, 427 



Kalte Haut und Unterhaut Abzesse, 

287, and see Scrofuloderma 
Kaposi's erysipelas perstans faciei, 297 
Kaposi's sarcoma, 343 

course, 343 

definition, 343 

diagnosis, 344 

etiology, 344 

prognosis, 344 

symptoms, 343 

synonyms, 343 

treatment, 344 

varieties, 343 
Karzinom, 320, and see Epithelioma 
Kelis, 198, and see Keloid 
Keloid, 198, 338 

course, 199 

definition, 198 

differential diagnosis, 199 

etiology, 199 

pathogenesis, 199 

prognosis, 199 

symptoms, 199 

synonyms, 198 

treatment, 199 

varieties, 199 
Keloid, acne, 272, 368 

Addison's, 205 



466 



INDEX 



Keratoderma palmaris et plantaris, 
195, and see Keratoma pal- 
maris et plantaris 
Keratoma, 194, and see Callus 
Keratoma, arsenical, differentiated 

from Callus, 194 
Keratoma blenorrhagicum, 277 

course, 277 

definition, 277 

differential diagnosis, 277 

etiology, 277 

prognosis, 277 

symptoms, 277 

treatment, 277 

varieties, 277 
Keratoma palmaris et plantaris, 195 

course, 195 

definition, 195 

differential diagnosis, 195 

prognosis, 196 

symptoms, 195 

synonyms, 195 

treatment, 195 

varieties, 195 
Keratosis, diagnosed from Callus, 194 
Keratosis, arsenical, differentiated 
from Keratoma palmaris et 
plantaris, 195 

congenital palmar and plantar, 195, 
and see Keratoma palmaris et 
plantaris 

exfoliativa congenita, 196 

follicularis, 186, 353, and see Psoro- 
spermosis 

follicularis contagiosa, 196 

differentiated from Psorospermosis, 
187 

follicularis spinosa, 181 

nigricans, 196 
Keratosis pilaris, 193 

course, 193 

definition, 193 

differential diagnosis, 193 

differentiated from Lichen acumina- 
tus, 180 

etiology, 193 

pathogenesis, 193 

prognosis, 193 

symptoms, 193 

synonyms, 193 

treatment, 193 

varieties, 193 
Keratosis senilis, 194, 317 

suprafollicularis (Unna), 193 

vegetans, 186, and see Psorospermosis 
Kerion Celsi, 248 

treatment, 251 
Kidneys, syphilis of, 427 

treatment of, 438 
King's evil, 287, and see Scrofuloderma 
Kleinflechte, 240, and see Pityriasis 
versicolor 



Koilonychia, 375 

Koplik's spots, 66, 67 

Kratze, 225, and see Scabies 

Kraurosis vulvae, 209 

Krebs, 320, and see Epithelioma 

Kupperrose, 369, and see Rosacea 

Laboratory methods of examination, in 

skin diseases, 27 
Ladrerie, 301, and see Lepra 
Larva migrans, 231 
Lausesucht, 227, and see Pediculosis 
Lead, eruption following use of, 63 
Leeches, 232 

Leichentuberkel, 286, and see Tubercu- 
losis verrucosa cutis 
Leishmania furunculosa, 234 
Lenticular papule, in Syphilis, 406 
Lentigo, 212 

Leontiasis, 301, and see Lepra 
Lepra, 279, 301 

course, 302 

definition, 301 

diagnosis, 302 

differentiated from Granuloma fun- 
goides, 307 
from Lupus erythematosus, 295 
from Lupus vulgaris, 284 
from Pityriasis versicolor, 240 
from Syphilis, 412 

etiology, 303 

hyperpigmentation in, 212 

prognosis, 303 

symptoms, 301 

synonyms, 301 

treatment, 303 

varieties, 302 
Lepra alba, 145, and see Psoriasis 

Arabum, 301, and see Lepra 
Lepre, 301, and see Lepra 
Leprides, 301 

Leprosy, 301, and see Lepra 
Leucemia, differentiated from Granu- 
loma fungoides, 308 
Leucemia cutis, 308 

course, 309 

definition, 308 

differential diagnosis, 310 

etiology, 310 

prognosis, 310 

symptoms, 309 

synonyms, 308 

treatment, 310 

varieties, 309 
Leucemic infiltrations differentiated 

from Sarcoid, 299 
Leucemides, 308, and see Leucemia 

cutis 
Leucoderma, 210 

from chrysarobin, 215 

psoriaticum, 215 

syphilitica, 411 



INDEX 



4G7 



Leuconychia, 375 

Leucoplacia, differentiated from Lupus 
erythematosus, 295 
of tongue, dili'erentiated from 
Gumma, 421 
Leucoplacia buccalis, 333, 387 
Leucosarcomatosis cutis, 310 
Lice, body, 229, and see Pediculosis 

corporis 
Lichen acuminatus, 179 
course, 180 
definition, 179 
differential diagnosis, 180 
differentiated from Dermatitis (Ec- 
zema), 123 
from Keratosis pilaris, 193 
from Lichen scrofulosorum, 290 
from Psoriasis, 149 
from Psorospermosis, 187 
etiology, 181 
pathogenesis, 181 
prognosis, 181 
symptoms, 179 
synonyms, 179 
treatment, 181 
Lichen albus, 176 
annularis, 176 

chronicus circumscriptus, 181, and 
see Lichen chronicus (sim- 
plex) 
Lichen chronicus (simplex), 181 
course, 182 
definition, 181 
differential diagnosis, 182 
etiology, 182 
pathogenesis, 182 
prognosis, 182 
symptoms, 181 
synonyms, 181 
treatment, 182 
varieties, 182 
Lichen erythematosus, 176 
linearis, 176 
moniliformis, 176 
morphoeicus, 176 
nitidus, 181 

differentiated from Lichen planus, 
177 
obtusus, 176 
obtusus corneus, 54, and see Prurigo 

nodularis 
pemphigoides, 176 

pilaris, 181, 193, and see Keratosis 
pilaris 
Lichen planus, 174 
course, 175 
definition, 174 
differential diagnosis, 176 
differentiated from Dermatitis (Ec- 
zema), 120 
from Gumma, 421 
from Lichen acuminatus, 180 



Lichen planus {continued) 
differentiated from Lichen chronicus 
(simplex), 182 
from Lichen scrofulosorum, 290 
from Lupus erythematosus, 295 
from Parapsoriasis, 157 
from Psoriasis, 149 
from Syphilis, 408 
etiology, 177 
hypertrophicus, 176 
pathogenesis, 177 
pigmentation in, 212 
prognosis, 179 
symptoms, 174 
synonyms, 174 
treatment, 178 
varieties, 175 
verrucosus, 176 
Lichen ruber (Hebra), 179, and see 

Lichen acuminatus 
Lichen ruber acuminatus (Kaposi), 
179, and see Lichen acumina- 
tus 
Lichen ruber planus, 174, and see 

Lichen planus 
Lichen sclerosus, 176 

differentiated from Lichen planus, 
176 
Lichen scrofulosorum, 290 
course, 290 
definition, 290 
diagnosis, 290 
differentiated from Lichen planus, 

177 
etiology, 290 
prognosis, 290 
symptoms, 290 
synonyms, 290 
treatment, 290 
Lichen scrofulosus, 290, and see Lichen 
scrofulosorum 
simplex, 181, and see Lichen chroni- 
cus (simplex) 
differentiated from Lichen planus, 
177 
spinulosus, 181 

differentiated from Keratosis pi- 
laris, 193 
from Lichen acuminatus, 180 
striatus, 176 
syphiliticus, 408 

differentiated from Lichen planus, 
177 
from Lichen scrofulosorum, 290 
tropicus, 373 

urticatus, 50, and see Infantile pru- 
rigo 
variegatus, 156 
Lichenification, 24, 104, 105, 172, 173, 
174 
differentiated from Lichen planus, 
177 



468 



INDEX 



Licliemfication (continued) 

primary, 181, and see Lichen chroni- 

cus (simplex) 
secondary, 1S3 

differentiated from Lichen chroni- 
cus (simplex), 182 
Lichens, 172 

types of, 172, 174, 175 
Light, as cause of skin diseases, 9 
Linea nigra, 212 
Lineae albicantes, 209, 215 

distensae, 215 
Lingual tuberculosis, 289 
Lipomata, 339 
Lips, diseases of, 385 
epithelioma of, 387 
syphilis of. differentiated from epi- 
thelioma, 387 
Liver, syphilis of, treatment, 438 
Louse, body, 229 
head, 227 
pubic, 230 
Lousiness, 227, and see Pediculosis 
Luetin test, in skin diseases, 29 
Lumpy jaw, 260 
Lungs, syphilis of, 428 

treatment, 438 
Lupoid, benign miliary, 297, and see 

Sarcoid 
Lupus erythematodes, 292, and see 

Lupus erythematosus 
Lupus erythematosus, 194, 292 
course, 294 
definition, 292 
differential diagnosis, 294 
differentiated from Alopecia areata, 
362 
from Dermatitis (Eczema), 121 
from Folliculitis decalvans, 359 
from Folliculitis suppurativa bar- 
bae staphylogenes, 267 
from Lupus vulgaris, 285 
from Raynaud's disease, 94 
from Sarcoid, 299 
etiology, 296 
prognosis, 296 
symptoms, 293 
synonyms. 292 
therapy, 296 
varieties, 294 
Lupus erythematosus discoides, dif- 
ferentiated from Rosacea, 
370 
Lupus erythematosus disseminatus, 
290, 296, and see Papulo- 
necrotic tuberculides 
Lupus erythematosus exanthematicus, 
296, and see Lupus erythema- 
tosus disseminatus 
Lupus erythematosus telangiectaticus, 
297 
differentiated from Sarcoid, 299 



Lupus miliaris, 284 

of Willan, 282, and see Lupus vul- 
garis 
pernio, 284, 297 
sclerosus, 286, and see Tuberculosis 

verrucosa cutis 
tuberculosis, 282, and see Lupus vul- 
garis 
tumidus, 284 

verrucosus, 286, and see Tuberculosis 
verrucosa cutis 
Lupus vulgaris, 282, 334 
course, 283 
definition, 282 
differential diagnosis, 284 
differentiated from Folliculitis sup- 
purativa barbae staphylogenes, 
267 
from Gumma, 420 
from Lupus erythematosus, 295 
from Sarcoid, 299 
etiology, 285 
prognosis, 285 
symptoms, 282 
synonyms, 282 
treatment, 285 
varieties, 284 
Lupus vulgaris erythematosus, 284 
Lupus vulgaris, of tongue, differenti- 
ated from Lingual tuberculo- 
sis, 289 
Lymph, disorders of, in relation to skin 

diseases, 16 
Lymph scrotum, 200 
Lymphadenides, 309 
Lymphadenie, 308, and see Leucemia 
cutis 
cutanea, 305, and see Granuloma 
fungoides 
Lymphadenitic erythroderma, 168, and 
see Pityriasis rubra (of He- 
bra) 
Lymphangioma tuberosum multiplex, 

352 
Lymphangitis, telangiectatic, 200 
Lymphoderma, 308, and see Leucemia 
cutis 
perniciosa cutis, 310 
Lymphogranulomatosis cutis, 310 
Lymphosarcomatosis cutis, 310 

Maculae ceruleae, 213, 230 
distensae, 209 

Macular syphiloderm, 405 

Macules, 18 

Maculopapular eruption in syphilis, 
408 

Madura foot, 260 

Mai de Meleda, 195, and see Keratoma 
palmaris et plantaris 

Malignant pustule, 274, and see An- 
thrax 



INDEX 



469 



Malignant .syphilis, 411 

treatment, 441 
Malleus, 275 

Marriage and Syphilis, 442 
Masern, 65, and see Measles 
Measles, 65 

complications, 67 

course, 66 

definition, 66 

diagnosis, 67 

differentiated from Dermatitis (Ec- 
zema), 118 

etiology, 67 

French, 68, and see German measles 

German, 68, and see German measles 

pathogenesis, 67 

prognosis, 67 

sequelae, 67 

symptoms, 66 

synonyms, 65 

varieties, 67 
Mediastinal syphilis, 428 
Medina worm, 232 
Melanin, 210 

hyperpigmentation derived from, 211 
Melanoma, 328 
Meningitis, cerebrospinal, 79 
Menopause, in its relation to skin dis- 
eases, 16 
Menstruation, in its relation to skin 

diseases, 16 
Mental diseases, associated with cu- 
taneous manifestations, 379 
Meralgia, 382 
Mercury, eruption following use of, 62 

in treatment of syphilis, 430, 434 

toxic effects of, 435 
Metabolic diseases, associated with cu- 
taneous manifestations, 379 
Metabolism, disturbed, as cause of skin 

diseases, 15 
Method of examination, in skin dis- 
eases, 26 
Mibelli, angiokeratoma of, 300 
Microscopic study of skin diseases, 

27 
Microsporosis, 242 

course, 243 

definition, 242 

differential diagnosis, 243 

etiology, 243 

pathogenesis, 243 

prognosis, 244 

symptoms, 242 

treatment, 244 

varieties, 243 
Mikulicz's cells, 276 
Miliaria crystallina, 373 

rubra, 373 
Miliary fever, 373 

lupus, differentiated from Acne, 366 

papule, in Syphilis, 408 



Miliary tuberculosis, disseminated, 

288 
Milium, 368 

colloid, 219 
Milroy's disease, 202 
Milzbrand, 274, and see Anthrax 
Mineral oils, as cause of skin dis- 
eases, 9 
Moeller's glossitis, 386 
Moist papules, in syphilis, 407 
Molluscum contagiosum, 185 

course, 185 

definition, 185 

differential diagnosis, 186 

etiology, 186 

pathogenesis, 186 

pathology, 185 

prognosis, 186 

symptoms, 185 

synonyms, 185 

treatment, 186 
Molluscum fibrosum, 337, and see Fi- 
broma 
Mongolian spots, 212 
Monilethrix, 361 

differentiated from Piedra, 242 
Morbilli, 65, and see Measles 
Morbus biblicus, 301, and see Lepra 

maculosus of Werlhoff, 81 
Morphine, pigmentation following use 

of, 213 
Morphoea, 205 

differentiated from Lupus erythema- 
tosus, 295 

guttate, 206 
Morpion, 230, and see Pediculosis pubis 
Morvan's disease, 380 
Morve, 275 
Mucous lesions, drugs producing, 56 

in syphilis, 403 
Mucous membranes, visible, diseases of, 
383 

patches, in syphilis, 403 
Multiple tumor-like growths, 209 
Mumps, 79 

Mutilations, hysterical, 97 
Mycosis, differentiated from Dermatitis 
(Eczema), 123 

differentiated from Sarcoma, 342 
Mycosis fungoides, 305, and see Granu- 
loma fungoides 

differentiated from Lepra, 303 
from Parapsoriasis, 157 
Mycosis fungoides d'emblee, 306 
Mycotic infiltrations, differentiated 

from Sarcoid, 299 
Myoma, 339 

diagnosis, 344 
Myxedema, 202 

Nails, anomalies of, 374 
atrophies of, 374, 375 



470 



INDEX 



Nails (continued) 
dermatitis of, 376 
diseases of, 374 
dystrophies of, 374, 375 
hypertrophy of, 374, 375 
infection of, 375, 377 
inflammation of, 375 
ingrown, 376 
injuries of, 375, 377 
syphilis of, 377 
tumors of, 375, 377 
transverse furrows, 375 
trichophytosis of, 248 
Naevus pigmentaire, 346, and see 

Nevus pigmentosus 
Nail-bed, inflammation of, 374 
Narbe, 197, and see Scar 
Nasal mucosa, diseases of, 384 
Necrosis, drugs producing, 56 
Neoplasms, 313, 315 

benign connective tissue, 337 

epithelial, 310 
malignant connective tissue, 341 
epithelial, 319 
Neo-arsphenamine in treatment of 

syphilis, 431 
Nephritis, 380 
Nerves, syphilis of, 425 
Nervous disorders, with cutaneous 
manifestations, 379 
syphilis, 424 

treatment, 439 
system, changes in cerebrospinal fluid 
in syphilis of, 425 
disturbances of in relation to skin 

diseases, 16 
rele of in urticaria, 44 
Nesselausschlag, 41, and see Urti- 
caria 
Nesselfieber, 41, and see Urticaria 
Nesselsucht, 41, and see Urticaria 
Nettle rash, 41, and see Urticaria 
Neurodermite, 149, 181, and see Lichen 

chronicus ( simplex ) 
Neurofibroma, 337, and see Fibroma 
Neurofibromatosis, 337, and see Reck- 
linghausen's disease 
Neuroma, 339 
Neurosyphilide, 405 
Nevi, see Nevus 

Nevoid disease, serpiginous infective, 
88, and see Angioma serpigi- 
nosum 
Nevus, 85, 313, 345, 346 
anemicus, 349 
araneus, 86 
classification of, 354 
diseases which are probably, 351 
flammeus, 348 
hairy, 346 

lupus, 88, and see Angioma serpigi- 
nosum 



Nevus (continued) 

pigmentary, 346, and see Nevus pig- 
mentosus 

pigmented, 335 
Nevus pigmentosus, 346 

course, 346 

definition, 346 

differential diagnosis, 347 

etiology, 347 

prognosis, 347 

symptoms, 346 

synonyms, 346 

treatment, 347 

varieties, 347 
Nevus pilosus, 346 

simplex, 348 

spilus, 346, and see Nevus pigmen- 
tosus 

vasculaire, 347, and see Vascular nevi 

vascular, 347, and see Vascular nevi 

vascularis, 347, and see Vascular nevi 

vasculosus, 347, and see Vascular 
nevi 
Nikolsky's sign, in Pemphigus foli- 

aceus, 138 
Nipple, eczematous epithelioma of, 328 
Noli me tangere, 325, and see Epithe- 
lium, basal celled 
Noma, 96, 277 

definition, 96 

etiology, 96 

pathogenesis, 96 

prognosis, 97 

symptoms, 96 

synonyms, 96 

treatment, 96 

varieties, 96 
Non-autochthonous skin diseases, 12 
Non-miliary tubercular ulcers, 288 
Non-protein toxins as cause of urti- 
caria, 44 
Nosocomial gangrene, 277 

Occupation, as cause of skin diseases, 

10 
Occupational dermatitis, 113 
Ocular syphilis, 426 
Oidiomycosis, 255, and see Blastomy- 
cosis 
Onychatrophia, 375 
Onychauxis, 375 
Onychia maligna, 376 

syphilitica, 378 
Onychogryphosis, 375 
Onycholysis, 375 
Onychomadesis, 375 
Onychonychia, 375, 376 
Onychorrhexis, 375 
Opium and its derivatives, eruption 

following use of, 60 
Oriental boil, 233 

course. 233 



INDEX 



471 



Oriental boil (continued) 

definition, 233 

differential diagnosis, 233 

etiology, 234 

pathogenesis, 234 

prognosis, 234 

symptoms, 233 

synonyms, 233 

treatment, 234 

varieties, 233 
Oriental button, 233, and see Oriental 
boil 

sore, 233, and see Oriental boil 
Oroya fever, 236 
Ortie, 41, and see Urticaria 
Osteitis, syphilitic, 403 
Osteomata, 339 
Oxyuris vermicularis, 232 

Pachydermia, 199, and see Elephanti- 
asis 
Paget's disease, 189, 328 
Panaritium, 376 

Papillomata differentiated from Granu- 
loma pyogenicum, 278 
Papillomatous warts differentiated 
from Condyloma acuminatum, 
188 
Papular dermatitis differentiated from 
Prurigo, 53 
syphiloderm, 406 
Papule, 19 

acuminate, in syphilis, 408 
lenticular, in syphilis, 406 
miliary, in syphilis, 407, 408 
Papulonecrotic tuberculides, 290 
course, 291 
definition, 291 
differential diagnosis, 292 
differentiated from Lupus vulgaris, 

285 
etiology, 292 
prognosis, 292 
symptoms, 291 
synonyms, 290 
treatment, 292 
varieties, 291 
Papnlotubercular carcinoma, 327 
Paraffin prosthesis, 202 
Parakeratosis variegata, 156 
Parasites, 223 

animal, as cause of skin diseases, 10, 

14 
lesions caused by, 224 
Parasitic diseases, 221, 223 
Parapsoriasis, 156 
course, 156 
definition, 156 
differential diagnosis, 157 
differentiated from Dermatitis (Ec- 
zema), 122 
from Lichen planus, 177 



Parapsoriasis (continued) 
differentiated from Purpura annu- 
laris telangiectoides, 87 
etiology, 157 
pathogenesis, 157 
prognosis, 157 
symptoms, 156 
synonyms, 156 
treatment, 157 
varieties, 157 
Parapsoriasis en gouttes, 156 
en plaques, 156 
guttata, 156 
Paratuberculosis, 291, and see Papulo- 
necrotic tuberculides 
Paronychia, 376 
suppurative, 377 
syphilitica, 378 
Pearls, 326 

Pediculoides ventricosus, 232 
Pediculose, 227, and see Pediculosis 
Pediculosis, 227 
course, 227 
definition, 227 
symptoms, 227 
synonyms, 227 
varieties, 227 
Pediculosis capitis, 227 
diagnosis, 228 

differentiated from Dermatitis (Ec- 
zema), 119 
etiology, 228 
pathogenesis, 228 
symptoms, 227 
synonyms, 227 
treatment, 228 
Pediculosis corporis, 229 
course, 229 
definition, 229 
differential diagnosis, 229 
differentiated from Dermatitis (Ec- 
zema), 119 
etiology, 229 
pathogenesis, 229 
prognosis, 230 
symptoms, 229 
synonyms, 229 
treatment, 230 
Pediculosis pubis, 230 
course, 230 
definition, 230 
differential diagnosis, 230 
differentiated from Dermatitis (Ec- 
zema), 119 
etiology, 230 
pathogenesis, 230 
pigmentation in, 213 
prognosis, 231 
symptoms, 230 
synonyms, 230 
treatment, 231 
varieties, 230 



472 



im)Ex 



Pediculosis vestimenti, 229, and see 

Pediculosis corporis 
Pediculus capitis, 228 

corporis, 229 

vestimenti, 228 
Pelade, 361, and see Alopecia areata 
Poliosis rheumatica, 81 
Pemphigoides maligna, 139, and see 

Pemphigus vegetans 
Pemphigus differentiated from Derma- 
titis (Eczema), 120 

from Dermatitis gangrenosa infan- 
tum, 95 

from Dermatitis herpetiformis, 142 

from Impetigo contagiosa, 262 
Pemphigus, acute febrile grave, 134, 

and see Pemphigus acutus 
Pemphigus acutus, 134 

course, 135 

definition. 135 

differential diagnosis, 135 

etiology, 135 

pathogenesis, 135 

prognosis, 136 

symptoms, 135 

synonyms, 134 

treatment, 136 

varieties, 135 
Pemphigus foliaceus, 137 

course, 139 

definition, 137 

differential diagnosis, 139 

etiology, 139 

pathogenesis, 139 

prognosis, 139 

symptoms, 137 

treatment, 139 
Pemphigus gangrenosus, 94, and see 
Dermatitis gangrenosa infan- 
tum 
Pemphigus vegetans, 139 

course, 140 

definition, 139 

differential diagnosis, 140 

differentiated from Syphilis, 407 

etiology, 141 

pathogenesis, 141 

prognosis, 141 

symptoms, 139 

synonyms, 139 

treatment, 141 

varieties, 140 
Pemphigus vulgaris, 136 

course, 136 

definition, 136 

differential diagnosis, 136 

etiology, 137 

pathogenesis, 137 

prognosis, 137 

symptoms, 136 

treatment, 137 

varieties, 136 



Penis, cancer of, 330 

Periosteum, syphilis of, treatment, 440 

Periostitis, syphilitic, 403 

Perleche, 266 

Perniciosa, 308, and see Leucemia cutis 

Pertussis, 79 

Peruvian wart, 235, and see Verruga 

peruviana 
Petit vereole, 72, and see Variola 
Phenolphthalein, eruption following use 

of, 65 
Phlegmon, 272 
Phosphoridrosis, 372 
Phthiriase, 227, and see Pediculosis 
Phthiriasis, 227, 229, and see Pedicu- 
losis, and Pediculosis corporis 

palpebrarum, 230 
Physical agents, causing skin diseases, 

9 
Pian, 234, and see Frambesia 
Piebald skin, 214, and see Vitiligo 
Piedra, 241 

Pigment, atrophy, 214, and see Depig- 
mentation 
Pigmentary disease, 210 

syphilides, 411 
Pigmentation, disturbances of, 210 

drugs producing, 56 

due to drugs, 14 

treatment of, 213 
Pigmented mole, 346, and see Nevus 

pigmentosus 
Pimples, 364, and see Acne 
Pinta, 253 

Pityriasis circinata, 157, and see 
Pityriasis rosea 

lichenoides chronica, 156 

pilaris, 193, and see Keratosis pilaris 
Pityriasis rosea, 157 

course, 158 

definition, 157 

differential diagnosis, 158 

differentiated from Dermatitis (Ec- 
zema), 122 
from Seborrhea, 162 
from Syphilis, 407 

etiology, 158 

pathogenesis, 158 

prognosis, 159 

symptoms, 157 

synonyms, 157 

treatment, 159 

varieties, 158 
Pityriasis ros6e, 157, and see Pityriasis 
rosea 

rubra, 300 
Pityriasis rubra (of Hebra), 168 

course, 168 

definition, 168 

differential diagnosis, 169 

differentiated from Dermatitis (Ec- 
zema), 123 



INDEX 



473 



Pityriasis rubra (of Hebra) {contd.) 

differentiated from Lichen acumi- 
nata, 180 

etiology, 1C9 

pathogenesis, 1G9 

prognosis, 170 

symptoms, 1G8 

synonyms, 168 

treatment, 169 
Pityriasis rubra pilaris (Devergie), 
179, and see Lichen acuminatus 
Pityriasis versicolor, 240 

course. 240 

definition, 240 

differential diagnosis, 240 

differentiated from Dermatitis (Ec- 
zema), 122 

etiology, 241 

pathogenesis, 241 

prognosis, 241 

symptoms, 240 

synonyms, 240 

treatment, 241 
Pituitary body, disturbances of, as 

cause of skin diseases, 16 
Plaques of tongue, benign, 386 
Plica polonica, 228 
Pocken, 72, and see Variola 
Pocks, the, 72, and see Variola 
Pompholyx. 103, 134, and see Pem- 
phigus, and Cheiroponipholyx 

differentiated from Epidermophytia 
inguinalis, 252 
Porokeratosis, 196 
Portwine mark, 348 
Postmortem pustules, 273 
Precancerous dermatoses, 188, 331 
Pregnancy, and syphilis, 442 

in its relation to skin diseases, 16 
Preleucemic dermatoses, 309 
Premycosis differentiated from Derma- 
titis (Eczema), 123 
Premycotic erythroderma differentiated 
from Pityriasis rubra of He- 
bra, 169 
Prepuce, diseases of, 388 
Pressure, as cause of skin diseases, 9 
Prickly heat, 373 
Primar affect, 397, and see Syphilis, 

acquired, primary stage 
Primary lesion, 397, and see Syphilis, 
acquired, primary stage 

sore, 397, and see Syphilis, acquired, 
primary stage 
Professional eczema, 113 
Profeta's law, 444 

Protein toxins as cause of Urticaria, 43 
Protozoa, as cause of disease, 10, 14 

infection caused by, 233 
Prurigo, 51 

course, 52 

definition, 51 



Prurigo ( continued ) 

differential diagnosis, 52 
differentiated from Dermatitis (Ec- 
zema), 121 
from Infantile prurigo, 51, 53 
from Pediculosis corporis, 229 
from Scabies, 226 
etiology, 53 
pathogenesis, 53 
prognosis, 54 
symptoms, 52 
synonyms, 51 
treatment, 53 
varieties, 52 
Prurigo agria, 52 
ferox, 52 
gravis, 52 

infantile, 50, and see Infantile pru- 
rigo 
mitis, 52 
Prurigo nodularis, 54 
course, 54 
definition, 54 
etiology, 54 
pathogenesis, 54 
prognosis, 54 
symptoms, 54 
synonyms, 54 
treatment, 54 
Prurigo, of Hebra, 51, and see Prurigo 
simplex, 52 

temporanea, 50, and see Infantile 
prurigo 
Prurit avec lichenification, 181, and see 
Lichen chronicus (simplex) 
circonscrit, 181, and see Lichen 
chronicus (simplex) 
Pruritus, 381 
ani, 387 

essentialis, treatment, 381 
vulvae, 388 
Pseudo-bothriomycosis, 277, and see 

Granuloma pyogenicum 
Pseudo-leucemia, differentiated from 

Leucemia cutis, 310 
Pseudo-leucemia cutis, 308, and see 

Leucemia cutis 
Pseudo-pelade, 359, and see Folliculitis 
decalvans 
differentiated from Alopecia areata, 
362 
from Favus, 255 
from Lupus erythematosus, 295 
Pseudo-xanthoma elasticum, 218 
Psora, 145, and see Psoriasis 
Psoriasiform dermatitis, 145 
Psoriasis, 145 
course, 147 
definition, 145 
differential diagnosis, 147 
differentiated from Dermatitis (Ec- 
zema), 122 



474: 



INDEX 



Psoriasis ( continued ) 
differentiated from Keratoma bleno- 
rrhagieum, 277 
from Keratoma palmaris et plan- 

taris, 195 
from Lichen chronicus (simplex), 

182 
from Lichen planus, 176 
from Lupus erythematosus, 294 
from Microsporosis, 243 
from Parapsoriasis, 157 
from Seborrhoea, 162 
from Syphilis, 407, 413 
etiology, 149 
pathogenesis, 149 
symptoms, 145 
synonyms, 145 
treatment, 151 
varieties, 147 
Psoriasis circinata, 146 
diffusa, 146 
discoidea, 146 
figurata, 146 
follicularis, 146 
geographica, 146 
guttata, 146 
gyrata, 146 
inveterata, 146 
nummularis, 146 
orbicularis, 146 
ostracea, 146 
punctata, 146 
rupioides, 146 
Psorospermosis, 186 
course, 187 
definition, 186 
differential diagnosis, 187 
etiology, 187 
pathogenesis, 187 
prognosis, 187 
symptoms, 186 
synonyms, 186 
treatment. 187 
Psorospermosis follicularis vegetans, 

186, and see Psorospermosis 
Peterygium, 375 

Puberty, in its relation to skin dis- 
eases, 16 
Pubic louse, 230 

Pudenda, ulcerating granuloma of, 235 
Purpura, 55, 80, 212 
drugs producing, 56 
etiology, 82 
in newborn, 81 
prognosis, 82 
therapy, 82 
Purpura annularis telangiectoides, 86 
course, 87 
definition, 86 
differential diagnosis, 87 
etiology. 87 
pathogenesis, 87 



Purpura annularis telangiectoides 
{continued) 

prognosis, 87 

symptoms, 86 

synonyms, 86 

treatment, 87 

varieties, 87 
Purpura, arthritic, 80 

hemorrhagica, 81 

Henoch's, 81 

mechanical, 80 

primary, 80 

rheumatica, 81 

simplex, 80 

symptomatica, 80 

variolosa, 74 
Pustular syphilides, 409, 410 
Pustules, 20 

drugs producing, 56 

due to drugs, 14 

postmortem, 273 
Pyodermas, 272 

Pyodermites, 273, and see Pyodermas 
Pyogenic infection under nail, 377 
Pyramidon, eruption following use of, 
64 

Quincke's edema, 48, and see Angio- 
neurotic edema 
Quinine, eruption following use of, 59 
Quinquaud's disease, 359, and see Fol- 
liculitis decalvans 

Race, as cause of skin diseases, 11 
Rash, scarlet, 69, and see Scarlatina 
Rat-bite fever, 237 

course, 237 

definition, 237 

differential diagnosis, 238 

etiology, 238 

pathogenesis, 238 

prognosis, 238 

symptoms, 237 

treatment, 238 

varieties, 237 
Raynaud's disease, 93 

course, 93 

definition, 93 

differential diagnosis, 93 

etiology, 94 

pathogenesis, 94 

prognosis, 94 

symptoms, 93 

synonyms, 93 

treatment, 94 
Recklinghausen's disease, 219, 337, 353, 

and see Fibroma 
Recurrent roseola in Syphilis, 405 
Recurrent summer eruption, 143 
Reinfection, in syphilis, 399 
Rhagades, 22 
Rhinophyma, 369 






INDEX 



475 



Ehinoscleroma, 276 
course, 276 
definition, 276 
differential diagnosis, 276 
etiology, 276 
prognosis, 276 
symptoms, 276 
synonyms, 276 
treatment, 276 
Einged eruptions, 300 
Eingworm, 244, and see Trichophytosis 
differentiated from Dermatitis (Ec- 
zema), 119 
from Favus, 255 
from Impetigo contagiosa, 262 
from Pityriasis versicolor, 241 
from Seborrhoea, 162 
etiology, 249 
of beard, treatment, 251 
of body, treatment, 251 
of nails, treatment, 251 
of scalp, 245 

treatment, 250 
papular, 246 
pathogenesis, 249 
pustular, 247 
squamous, 246 
Eocky Mountain spotted fever, 78 
Eodent ulcer, 319, 325, and see Epi- 
thelioma, basal celled 
Eoentgen carcinoma, 335 
Eosacea, 369 
course, 370 
definition, 369 
diagnosis, 370 

differentiated from Dermatitis (Ec- 
zema) , 118 
from Erysipelas, 265 
from Lupus erythematosus, 294 
etiology, 370 
prognosis, 370 
symptoms, 369 
synonyms, 369 
treatment, 370 
Eose, 264, and see Erysipelas 
Eoseola, epidemic, 68, and see German 
measles 
infantilis, 40 
scarlatiniforme, 34, 171, and see 

Erythema scarlatiniforme 
syphilitic, 405 
Eotheln, 68, and see German measles 
Eothlauf, 264, and see Erysipelas 
Eotz, 275, and see Equinia 
Eougeole, 65, and see Measles 
Eubella, 68, and see German measles 
Eubeola, 65, 68, and see Measles, and 

German measles 
Eubeola, 68, and see German measles 
Eupia escharotica, 94, and see Derma- 
titis gangrenosa infantum 
Eupial syphilide, 417 



EusselPs bodies, 276 

Saccharomycosis, 255, and see Blas- 
tomycosis 
Salicylates, eruption following use of, 

65 
Saprophytic skin diseases, 240 
Sarcoid, 297 
Boecke's, 298 
course, 298 
definition, 297 
differential diagnosis, 298 
differentiated from Gumma, 419 
from Lupus erythematosus, 295 
from Lupus vulgaris, 285 
etiology, 299 
multiple benign, 297 
prognosis, 299 
symptoms, 298 
synonyms, 297 
treatment, 299 
varieties, 298 
Sarcoma, 341 
course, 341 
definition, 341 
diagnosis, 344 
differential diagnosis, 342 
differentiated from Granuloma fun- 
goides, 308 
from Ehinoscleroma, 276 
from Sarcoid, 299 
etiology, 342 
symptoms, 341 
treatment, 343 
varieties, 341 
Sarcoma cutis multiplex idiopathicum, 
305, and see Granuloma fun- 
goides 
idiopathicum multiplex hemorrhagi- 
cum, 343, and see Kaposi's 
sarcoma 
hypodermic, 341 

Kaposi's, 343, and see Kaposi's sar- 
coma 
lymphadenoides myxoides, 305, and 

see Granuloma fungoides 
melanotic, 342 
nevo-, 341 
secondary, 342 
Sarcomatosis cutis, 305, and see Granu- 
loma fungoides 
Savill's disease, 170 
Scabies, 225 
course, 226 
definition, 225 
differential diagnosis, 226 
differentiated from Dermatitis (Ec- 
zema), 119 
from Prurigo, 52 
from Infantile prurigo, 51 
etiology, 226 
pathogenesis, 226 



476 



INDEX 



Scabies (continued) 

prognosis, 227 

symptoms, 225 

synonyms, 225 

treatment, 226 

varieties, 226 
Scales, 21 
Scar, 197 

definition, 197 

differential diagnosis, 198 

etiology, 198 

pathogenesis, 198 

prognosis, 198 

symptoms, 197 

synonyms, 197 

treatment, 198 

varieties, 19-3 
Scars, 23 

pigmentation in, 212 
Scarlatina, 69 

complications, 70 

course, 70 

definition, 69 

diagnosis, 71 

differentiated from Dermatitis (Ec- 
zema), 118 
from Erythema scarlatiniforme, 35 

etiology, 71 

pathogenesis, 71 

prognosis, 72 

symptoms, 69 

synonyms, 69 

varieties, 70 
Scarlatine, 69, and see Scarlatina 
Scarlatiniform erythema, 34, and see 
Erythema scarlatiniforme 

roseola, 34, and see Erythema scarla- 
tiniforme 
Scarlatinoide, 34, 171, and see Eryth- 
ema scarlatiniforme 
Scarlet fever, 69, and see Scarlatina 

rash, 69, and see Scarlatina 
Schamberg's disease, 87 
Schanker, 397, and see Syphilis, ac- 
quired, primary stage 
Scharlach, 69, and see Scarlatina 
Scherende flechte, 244, 245, and see 

Trichophytosis 
Schonlein's disease, 81 
Schrei exanthem, 40 
Schuppenfleehte, 145, and see Psoriasis 
Schwiele, 194, and see Callus 
Scirrhous carcinoma, 327 
Sclerema, adult, 204, and see Sclero- 
derma 

neonatorum, 201 
Scleriasis, 204, and see Scleroderma 
Sclerodactylia, 206 
Scleroderma, 204 

course, 205 

definition, 205 

differential diagnosis, 207 



Scleroderma (continued) 

differentiated from Raynaud's dis- 
ease, 94 

etiology, 207 

pathogenesis, 207 

prognosis, 207 

symptoms, 205 

synonyms, 204 

treatment, 207 

varieties, 207 
Scleroderma, circumscribed, 206 

neonatorum, 201 
Sclerodermie, 204, and see Scleroderma 
Sclerodermic, 204, and see Scleroderma 
Sclerose, 397, and see Syphilis, ac- 
quired, primary stage 
Sclerosis, 397, and see Syphilis, ac- 
quired, primary stage 
Scorbutus, 82, and see Scurvy 
Scrofula, 287, and see Scrofuloderma 
Scrofuloderma, 287 

course, 288 

definition, 287 

differential diagnosis, 288 

etiology, 288 

prognosis, 288 

symptoms, 287 

synonyms, 287 

treatment, 288 

varieties, 288 
Scrotal tongue, 386 
Scrotum, lymph, 200 
Scurvy, 82 
Scutulum, 254 
Sebaceous cysts, 334, 368 

differentiated from Molluscum con- 
tagiosum, 186 
Sebaceous diseases, 364 
Seborrhoea, 159 

course, 160 

definition, 159 

diagnosis, 162 

differentiated from Favus, 255 
from Lupus erythematosus, 294 
from Microsporosis, 243 
from Parapsoriasis, 157 
from Pityriasis rosea, 158 
from Pityriasis versicolor, 240 
from Syphilis, 406, 408 

etiology, 162 

pathogenesis. 162 

prognosis, 165 

symptoms, 160 

treatment, 163 

varieties, 161 
Seborrhoea congestiva, 292, and see 
Lupus erythematosus 

oleosa, 161 

sicca, 161 
Seborrhoeal baldness, 161 

dermatitis, 159, 161 

keratoma, 333 



INDEX 



477 



Seborrhoeic warts, 317 
Senile atrophy, 208 

dermatitis, 11G 
Sepsis, 79 

differentiated from Blastomycosis, 
257 
Serum sickness, 57 

course, 57 

definition, 57 

diagnosis, 57 

etiology, 58 

pathogenesis, 58 

prognosis, 58 

symptoms, 57 

treatment, 58 
Seven years' itch, 225, and see Scabies 
Sex, in relation to skin diseases, 11 
Sexual organs, disturbances of, as 

cause of skin diseases, 16 
Shingles, 100, and see Zoster 
Silver, eruptions following use of, 

63 
Skeletal system, syphilis of, 427 
Skin, elastic, 202 

laxness of. 219, and see Cutis laxa 

lesions, see Cutaneous lesions 
Sklerose, 397, and see Syphilis, ac- 
quired, primary stage 
Smallpox, 72, and see Variola 

differentiated from Dermatitis gan- 
grenosa infantum, 95 

virus, 58 
Sore, cold, 98, and see Herpes 
Spedalsked, 301, and see Lepra 
Spitz blattern, 75, and see Varicella 
Spitzencondylon, 187, and see Condy- 
loma acuminatum 
Spirochete of syphilis, 392 

dissemination of, 392 
Spleen, gumma of, 428 
Spotted fever, 79, and see Cerebrospinal 
fever 

of Rocky Mountains, 78 
Sporotrichosis ( Schenck-Hecktoen ) , 258 

course, 259 

definition, 258 

differential diagnosis, 259 

differentiated from Blastomycosis, 
257 
from Lupus vulgaris, 285 
from Scrofuloderma, 288 

etiology, 259 

pathogenesis, 259 

prognosis, 259 

symptoms, 258 

treatment, 259 

varieties, 259 
Sprue. 386 

Sputum, examination of, in skin dis- 
eases, 28 
St. Anthony's fire, 264, and see Ery* 
sipelas 



Staphylococcus folliculitis differenti- 
ated from Acne, 366 
infections of skin, 261 
Steatomas, 368 
Stings, 231 
Stomatitis, aphthous, 386 

gangrenous, 96, and see Noma 
ulcerative, 386 
Strawberry tongue, 69 
Streptococcus infections of skin, 261 
Striae, 209 

Strophulus infantum, 50, and see In- 
fantile prurigo 
Stye, differentiated from Molluscum 

contagiosum, 186 
Subungual hemorrhages, 377 
Sudamina, 373 
Sulphonal, eruptions following use of, 

64 
Superinfection, in Syphilis, 399 
Sweat glands, diseases of, 371 
Sycose, 266, and see Folliculitis sup- 
purativa barbae staphylogenes 
Sycosis parasitica, 247, and see Tri- 
chophytosis barbae 
non-parasitica, 266, and see Follicu- 
litis suppurativa barbae sta- 
phylogenes 
staphylogenes, 266, and see Follicu- 
litis suppurativa barbae sta- 
phylogenes 
vulgaris, 266, and see Folliculitis 
suppurativa barbae staphylo- 
genes 
Symmetrical gangrene of the extremi- 
ties, 93, and see Raynaud's 
disease 
Syphilides, 279, and see Syphiloderm 
annular, 408 
corymbiform, 406 
corymbose, 406 
discoid, 407 
pigmentary, 411 
pustular, 409, 410 

secondary, regional peculiarities, 412 
rupial, 417 
tubero-circinate, 417 
tubero-serpiginous, 417 
tubero- squamous, 417 
tubero-ulcerative, 417 
varicelliform, 410 
Syphilis, 391 

acuminate papule in, 408 
biology of early stage, 393 
cardiovascular, 426 
chancre, 397 
mixte, 399 
redux, 399 
definition, 392 
d'emblee, 399 

differentiated from Blastomycosis, 
257 



478 



INDEX 



Syphilis (continued) 

differentiated from Dermatitis (Ec- 
zema), 121 

from Dermatitis gangrenosa infan- 
tum, 95 

from Ecthyma, 263 

from Epithelioma, 323 

from Folliculitis decalvans, 359 

from Frambesia, 235 

from Granuloma fungoides, 307 

from Herpes, 99 

from Keratoma blenorrhagicum, 277 

from Lepra, 302 

from Lupus vulgaris, 284 

from Oriental boil, 234 

from Parapsoriasis, 157 
. from Pemphigus vegetans, 140 

from Pityriasis versicolor, 241 

from Psoriasis, 148 

from Rhinoscleroma, 276 

from Sarcoid, 299 

from Scrofuloderma, 288 

from Verruga peruviana, 236 
ecthymatous, 411 
general aspects of, 391, 394 
hyperpigmentation in, 212 
incubation period, primary, 391 

secondary, 391 
infectious mechanism of, 391 
lenticular papule in, 406 
lesion, initial, 391 

primary, 391 
maculo-papular eruption in, 408 
malignant, 411 

treatment, 441 
management, 430 

by arsphenamin, 430 

by arsphenamin and other reme- 
dies, 435 

by iodides, 430, 435 

by mercury, 430, 434 

by neo-arsphenamine, 430 
marriage and. 442 
mediastinal, 428 
miliary papule in, 408 
mode of infection, 391 
moist papule in, 407 
nervous, 424 

period of secondary latency, 391 
pregnancy and, 442 
prognosis, 441 
reinfection in, 399 
spirochete in, 392 
stages of, 391 

primarv, 391 

treatment, 436, 437 

secondary, 391 
treatment, 437 

tertiary, 392, 394 
treatment, 437 
superinfection in, 399 
tertiary period, 394 



Syphilis (continued) 

treatment, 436, 437 

treated, 396 

visceral, 428 

Wassermann test in, 395 
Syphilis acquired, non-cutaneous mani- 
festations, 423 

period of dissemination and florition, 
402, and see Syphilis acquired, 
secondary stage 
Syphilis acquired, primary stage, 397 

chancre, 397, 399 

course, 398 

diagnosis, 400 

incubation period, 397 

prognosis, 401 

reinfection, 399 

superinfection, 399 

symptoms, 397 

synonyms, 397 

varieties, 398 
{Syphilis, acquired, secondary stage, 402 

central nerve involvement, 404 

course, 404 

eruption, 402, 405 

humoral changes, 404 

lymph glands, 403 

mucous lesions, 403 

mucous patches, 403 

osteitis, 403 

periostitis, 403 

prognosis, 414 

signs, 402 

symptoms, 402 

varieties of eruption, 405, 412 

visceral signs. 403 
Syphilis, acquired, tertiary stage, 415 

differential diagnosis, 418 

general characteristics, 415 

gumma, 416 

summary, 422 
Syphilis, congenital, 415, 444 

blood diseases in, 452 

bones in, 452 

cardiovascular diseases in, 452 

eye symptoms in, 452 

Fournier's delayed, 447 

joints in, 452 

lymphatic glands in, 452 

mode of infection in, 454 

nervous manifestations in, 452 

respiratory phases of, 453 

skin lesions in, 451 

summary, 453 

treatment, 440, 454 

Wassermann reaction in, 395, 453 
Syphilitic acne, 409 

leucoderma, 411. 

osteitis, 403 

periostitis, 403 

roseola, 405 
Syphiloderm, 402, 405 



INDEX 



479 



Syphiloderm (continued) 

differentiated from Dermatitis (Ec- 
zema), 121 

macular, 405 

papular, 406 
Syringoma, 352 
Syringomyelia, 380 

differentiated from Lepra, 303 

Tache pigmentaire, 346, and see Nevus 

pigmentosus 
Taches bleuatres, 230 
Taenia solium, cysterci of, 232 
Tar, as cause of skin diseases, 9 
Tattooing, 213 

removal of marks, 213 
Teeth, Hutchinson's, 450 
Teigne faveuse, 253, and see Favus 
tondante, 244, 245, and see Tricho- 
phytosis 
Telangiectasia, essential, 84 

follicularis annulata, 86, and see 
Purpura annularis telangiec- 
todes 
Telangiectasis, 83, 85 

essential, 89 
Testes, gumma of, 428 

syphilis of, 428 
Thread worm, 232 
Thyroid cachexia, 202 

disturbances in relation, to skin dis- 
eases, 15 
Ticks, 232 
Tinea, 245 

cruris, 252, and see Epidermophytia 

inguinalis 
favosa, 253, and see Favus 
imbricata, 253 
special forms of, 252 
tondens, 245 
tonsurans, 245 

versicolor, 240, and see Pityriasis 
versicolor 
Tongue, anomalies of, 385 
diseases of, 385 
epithelioma of, 387 
geographical, 386 
grooved, 386 
hairy black, 260, 386 
infections of, 385 
inflammation of, 385 
plaques of, benign, 386 
scrotal, 386 

syphilis of, differentiated from Epi- 
thelioma, 329, 387 
from lingual tuberculosis, 289 
tuberculosis of, 289 

differentiated from Epithelioma, 
329 
Tonsillitis, follicular, 79 
Toxins, bacterial, as cause of skin dis- 
eases, 14, 15 



Toxituberculides, 291, and see Papulo- 
necrotic tuberculides 
Triad, Hutchinson's, 450 
Trichina, 232 

Trichoepithelioma papulosum multi- 
plex, 352 
Trichomycosis palmellina, 241 
Trichonodosis, 361 
Trichorrhexis nodosa, 361 

differentiated from Piedra, 242 
Trichophyton, varieties of, 245 
Trichophyton acuminatum, 249 
crateriforme, 250 
cerebriforme, 250 
faviforme album, 250 
gypseum, 250 
rosaceum, 250 
violaceum, 250 
Trichophytosis, 244 
course, 245 
definition, 244 
etiology, 249 
pathogenesis, 249 
prognosis, 251 
symptoms, 244 
synonyms, 244 
treatment, 250 
unusual forms of, 253 
varieties, 245 
Trichophytosis barbae, 247 
capitis, 245 
corporis, 246 
of nails, 248 
Trypanosoma gambiense, 235 
Trypanosomiasis, 235 
Tubercular tumors, 287, and see Scro- 
fuloderma 
Tuberculides, 279, 280, 289 
nodular hypodermic, 297, and see 

Sarcoid 
papulonecrotic, 290, and see Papulo- 
necrotic tuberculides 
Tuberculin test in skin diseases, 29 
Tuberculosis, 279 
classification of, 280 
diagnosis of, 281 

differentiated from Blastomvcosis, 
257 
from Granuloma fungoides, 307 
from Gumma, 419, 421 
from Lepra, 302 
from Rhinoscleroma, 276 
diseases sometimes histologically re- 
sembling, 300 
hyperpigmentation in, 212 
infective, 280, 281 
miliary, 280, 282, 288 
non-infective, 280 
Tuberculosis colli quativa cutanea et 
subcutanea, 287, and see 
Scrofuloderma 
fungosa, 287, and see Scrofuloderma 



480 



INDEX 



Tuberculosis (continued) 

gummosa cutanea et subcutanea, 287, 

and see Scrofuloderma 
miliaris propria, 288 
ulcerosa miliaria, 288 
Tuberculosis verrucosa cutis, 286, 318 
definition, 286 
differential diagnosis, 286 
etiology, 286 
prognosis, 287 
symptoms, 286 
synonyms, 2S6 
treatment, 287 
varieties, 286 
Tuberculum anatomicum, 286, and see 

Tuberculosis verrucosa cutis 
Tumors, 19 

in or under nail, 377 
diagnosis of, 344 

malignant, in relation to skin dis- 
eases, 16 
multiple, with pruritus, 54, and see 
Prurigo nodularis 
Tylosis, 194, and see Callus 
Typhoid fever, 77 
diagnosis, 77 
etiology, 77 
rash, 77 

differentiated from syphilis, 406 
Typhus fever, 77 
diagnosis, 78 

rash differentiated from Syphilis, 406 
Tyroglyphus longior, 232 

Ulcerating granuloma of pudenda, 235 

Ulcers, 22 

Ulcus rodens, 325, and see Epithelioma, 

basal celled 
Ulerythema centrifugum, 292, and see 
Lupus erythematosus 
sycosiforme, differentiated from Fol- 
liculitis decalvans, 360 
Uncinarial dermatitis, 236, and see 

Ground itch 
Unguis incarnatus, 376 
Unna, X-cells of, 188 
Uridrosis, 372 

Urticaire, 41, and see Urticaria 
Urticaria, 33, 41 

anaphylaxis in, 43, 44, 45 
course, 42 
definition, 41 
differential diagnosis, 42 
differentiated from Erythema multi- 
forme, 36 
from Syphilis, 405 
etiology, 42 

mechanism of the lesion, 45 
prognosis, 48 
symptoms, 41 
synonyms, 41 
treatment, 45, 46 



Urticaria (continued) 

varieties, 42 
Urticaria annularis, 42 
bullosa, 42 
chronic, leaving brown spots, 49, and 

see Urticaria pigmentosa 
chronica infantum, 50, and see Infan- 
tile prurigo 
edematosa, 48, and see Angioneurotic 

edema 
evanida, 42 
factitia, 42 
giant, 42 
gyrata, 42 
hemorrhagica, 42 
papulosa, 42 
perstans, 42 

perstans verrucosa, 54, and see Pru- 
rigo nodularis 
Urticaria pigmentosa, 49 
course, 49 
definition, 49 
differential diagnosis, 49 
differentiated from Xanthoma tubero- 
sum, 217 
etiology, 50 
pathogenesis, 50 
prognosis, 50 
symptoms, 49 
synonyms, 49 
treatment, 50 
varieties, 49 
Urticaria solitaria, 42 
tuberosa, 42 
vesiculosa, 42 

with pigmentation, differentiated 
from Urticaria pigmentosa, 50 
Uta, 234 

Vaccination, bullous dermatitis follow- 
ing, 59 
Vaccinia, 58, 75 
Varicella, 75 
definition, 75 
diagnosis, 76 

differentiated from Dermatitis gan- 
grenosa infantum, 95 
from Impetigo contagiosa, 262 
from Pemphigus acutus, 135 
from Syphilis, 410 
etiology, 76 
pathogenesis, 76 
prognosis, 76 
symptoms, 76 
synonyms, 75 
Varicella gangrenosa, 94, and see Der- 
matitis gangrenosa infantum 
prurigo. 50, and see Infantile pru- 
rigo 
Varicelliform syphilide, 410 
Variola, 72 

complications, 74 



INDEX 



481 



Variola (continued) 

confluent variety, 73 

course, 73 

definition, 72 

diagnosis, 74 

differentiated from Pemphigus acu- 
tus, 135 

discrete variety, 73 

hemorrhagica pustulosa, 74 

pathogenesis, 74 

prognosis, 75 

symptoms, 72 

synonyms, 72 

varieties, 74 
Variolette, 75, and see Varicella 
Varioloid, 75 
Varix lymphaticus, 200 
Varus, 364, and see Acne 
Vascular disturbances, cutaneous re- 
actions due to, 33 
Vascular nevi, 347 

course, 348 

definition, 347 

differential diagnosis, 349 

etiology, 350 

prognosis, 350 

symptoms, 347 

synonyms, 347 

treatment, 350 

varieties, 348 
Vegetable oils, as cause of skin dis- 
eases, 9 

parasites, as cause of skin diseases, 
9, 14 

poisons, as cause of skin diseases, 9 
Venereal wart, 187, and see Condyloma 

acuminatum 
Vermes, as cause of skin diseases, 10, 

14 
Veronal, eruption following use of, 65 
Verruca acquisita, 318 

acuminata, 187, 318, and see Condy- 
loma acuminatum 

congenita, 318 

digitata, 318 

dorsi manus et pedis, 317 

filiformis, 317 

glabra, 318 

multiplex barbae, 317 

necrogenica, 286, 318, and see Tuber- 
culosis verrucosa cutis 

peruana, 318 

plana juvenilis, 188, 316 

senilis, 317 

vulgaris, 316 _^ 
Verrucae, 319 

Verrue, 316, and see Verrucae 
Verruga peruviana, 235 

course, 236 

definition, 235 

differential diagnosis, 236 

etiology, 236 



Verruga peruviana (continued) 

pathogenesis, 236 

prognosis, 237 

synonyms, 235 

treatment, 236 

varieties, 236 
Vesicles, 20 

caused by drugs, 14 

drugs producing, 56 
Vesicular diseases, 98 
Vincent's angina, 387 
Viscera, abdominal, syphilis of, 428 
Vitiligo, 214 

differentiated from Pityriasis versi- 
color, 241 
from Syphilis, 412 
Vulva, diseases of, 388 

pruritis of, 388 

Wandering edema, 48, and see Angio- 
neurotic edema 
Warts, 316, 319, and see Verruca vul- 
garis 

differentiated from Molluscum con- 
tagiosum, 186 

seborrhoeic, 317 

treatment, 317 
Wartzen, 316, and see Verrucae 
Washerwoman's itch, 253 
Wassermann reaction, in Scarlatina, 71 

in syphilis, 395, 453 
Wasserpocken, 75, and see Varicella 
Weichselzopf, 228 
Wens, 368 

Werlhoff, morbus maeulosus of, 81 
Wheals, 20 

caused by drugs, 14 

drugs producing, 56 
Whitlow, 376 

Windpocken, 75, and see Varicella 
Worm, Guinea, 232 

thread, 232 
Wounds, dissection, 273 



Xanthelasma, 218 

Xanthelasmoidea, 49, and see Urticaria 
pigmentosa 
differentiated from Xanthoma tuber- 
osum, 217 
Xantho-erythroderma perstans, 156 
Xanthoma, 216, and see Xanthoma 
tuberosum 
diabeticum, 218 

differentiated from Xanthoma 
tuberosum, 217 
multiplex, 216, and see Xanthoma 
tuberosum 
Xanthoma tuberosum, 216 
course, 217 
definition, 216 
differential diagnosis, 217 



4S2 



INDEX 



Xanthoma tuberosum {continued) 

differentiated from Urticaria pig- 
mentosa, 50 

etiology. 217 

pathogenesis. 217 

symptom?. 21G 

synonyms, 21 G 

varieties. 217 
X-cells. of Unna, 188 
Xeroderma pigmentosum. 212. 335. 353 
Xerosis. 191 
X-rays, hyperpigmentation from. 212 

Yaws. 234, and see Frambesia 



Zona, 100. and see Zoster 
Zoster. 100 

course, 101 

definition, 100 

differential diagnosis. 101 

differentiated from Dermatitis (Ec- 
zema). 119 

etiolosy. 102 

pathogenesis. 102 

prognosis, 103 

symptoms, 100 

synonyms, 100 

treatment, 102 

varieties, 101 



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